INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and methadone monitoring inspection conducted on August 27 - 29, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Echo Treatment Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection.
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Plan of Correction
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
The narcotic treatment program failed to provide documentation of narcotic treatment physician services at least one hour per week onsite for every ten patients based on a review of the patient weekly census and physician's work schedule on August 27, 2019.
The facility's patient census was 255 on March 13, 2019 and only 24 physician hours were documented.
The facility's patient census was 254 on June 24, 2019 and only 24 physician hours were documented.
The facility's patient census was 254 on July 1, 2019 and only 24 physician hours were documented.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director has scheduled additional physicians services to meet the one hour of on site physicians time per every ten patients. Director will monitor the census weekly and schedule additional physicians services as required to meet the on site physicians time of one hour per every ten patients weekly. |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
The facility's physician failed to document a review of dosage levels at least twice a year in patient record # 8 reviewed on August 28, 2019.
Patient # 8 was admitted May 2, 2016. The physician documented a dosage level review on March 11, 2019. Prior to March 2019, the last dosage review was documented on February 14, 2017.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The narcotic treatment physicians shall review the dosage levels at least
twice a year, with each review occurring at least 2 months apart, to determine a
patient's therapeutic dosage. Director will generate and monitor reports using the electronic health records system monthly and schedule patients for therapeutic dosage checks with physicians at least twice a year. Therapeutic dosage checks will be documented in the patients record. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
The narcotic treatment physician failed to document a determination of the proper dosage level for a patient by writing standing orders for the patient's induction phase in two of four patient records reviewed on August 27 - 29, 2019.
The following standing order was written by the physician in patient records # 2 and 7.
"Patient is to receive an initial dose of 30 mg methadone and monitor patient for one hour for signs and symptoms of adverse reaction. If no adverse signs and symptoms are present, redose patient 10 mg of methadone for a total dose of 40 mg."
These standing orders required the nurse to determine if the dosage change was appropriate for a patient. The physician is the only practitioner authorized to determine dosage orders and/or dosage changes.
Patient # 2 was admitted August 28, 2018. Standing orders were written by the physician on August 28, 2018.
Patient # 7 was admitted March 12, 2019. Standing orders were written by the physician on March 12, 2019.
In addition, the narcotic treatment physician failed to document a consult with the CRNP (Certified Registered Nurse Practitioner) who completed the patient examination prior to determining the patient's initial dose in patient records # 2, 3 and 5.
Patient # 2 was admitted August 28, 2018.
Patient # 3 was admitted January 7, 2019.
Patient # 5 was admitted April 2, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Medical Director held a meeting notifying and instructing all physicians and medical staff on the prohibition of standing orders for increases of medication on 9/5/2019. Medical Director will review on a monthly basis a random sampling of medication orders for compliance with the prohibition of standing orders for medication increases. Prior to the physician ordering the initial dose of methadone , a consultation will occur between the physician and the CRNP who completed the physical examination and will be documented in the patient's record by the physician. |
715.16(f) LICENSURE Take-home priveleges
(f) An exception granted under subsection (d) shall continue only for as long as the temporary disability or exceptional circumstance exists. When a patient is permanently disabled, that case shall be reviewed at least annually to determine whether the need for the exception still exists.
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Observations
The facility's physician failed to document an annual review of patient record # 8 to determine whether there still existed a need for a take home exception due to the patient's permanent physical disability based on a review of the patient's record on August 28, 2019.
Patient # 8 was admitted May 2, 2016. Patient # 8 was granted a 13 day take home supply of medication in 2017 due to a permanent physical disability.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project/Facility Director met with the physicians to provide training regarding the requirement for an annual documented review of all patients with a physical disability receiving take home medication by exception. Narcotic treatment program physicians will annually review whether there still exits a need for take home exceptions due to a patients permanent disability. Medical Director will review all patients records that have take home exceptions biannually for the completion of an annual physicians review of the need for continued take home exceptions. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
The facility failed to document a physical examination by the physician at least annually in three of six patient records reviewed on August 27 - 29, 2019.
Patient # 1 was admitted January 16, 2018. There was no documentation of an annual physical examination.
Patient # 6 was admitted January 4, 2017. The annual physical examination was not documented until February 6, 2019.
Patient # 10 was admitted February 16, 2018. The annual physical examination was not documented until March 18, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each patient will receive a documented annual physical examination. Director will generate a report of annual physical examinations due at the beginning of each month and patients will be scheduled before the due dates of their last physical examinations. |