Failure to Coordinate MOUD Dosage Changes with OTP Provider
Penalty
Summary
The facility failed to coordinate with the opioid treatment program (OTP) provider regarding changes to the medication dosage for opioid use disorder (MOUD) for a resident. The resident, who had a history of opioid use disorder and was being treated with methadone, also had diagnoses of Hepatitis B and Hepatitis C. After the resident experienced an opioid overdose and was hospitalized, the hospital coordinated with the OTP to temporarily reduce the methadone dose, with plans for the resident to return to the OTP for further dosing adjustments. Upon the resident's return, the OTP ordered a gradual increase of methadone back to the original dose. However, a physician assistant at the facility verbally changed the methadone dose to a lower amount based on recommendations from the resident's hepatology clinic, without documented coordination or consultation with the OTP provider. Facility staff administered the lower dose for several days, and the discrepancy was only discovered when the OTP noticed unused methadone in returned vials and questioned the facility. There was no documentation of communication with the OTP regarding the dose change or attempts to coordinate care between the OTP and the hepatology provider. Interviews with facility staff revealed a lack of clear policy regarding residents utilizing OTPs and confusion about which provider was responsible for managing methadone dosing for opioid use disorder. The medical director clarified that only the OTP should manage methadone dosing for opioid use disorder, but this protocol was not followed in the resident's case. The facility did not have documentation of proper coordination with the OTP, leading to the identified deficiency.