F0656

D

Failure to Include Methadone Therapy and Clinic Visits in Resident Care Plans

Cheswick, Pennsylvania Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

Surveyors determined that the facility failed to develop comprehensive, individualized care plans that addressed all identified care needs for two residents. Facility policy on MDS/RAI/Care Planning, last reviewed on 11/1/25, stated that the care planning process is an interdisciplinary tool and that care plans are to be assessed at least quarterly and reviewed by the interdisciplinary team. For one resident admitted on an unspecified date, the MDS dated 1/21/26 documented diagnoses of diabetes, anxiety, and chronic pain. Physician orders dated 1/14/26 showed Methadone HCl Oral Concentrate 10 mg/mL, 8 mL by mouth twice daily for chronic back pain, and the physician’s initial comprehensive visit on 1/16/26 documented that the resident went to an outpatient methadone clinic for prescriptions.

Review of this resident’s care plan, initiated on 1/19/26, showed a problem for pain related to chronic pain but did not include any information about the resident’s methadone use or methadone clinic appointments. For a second resident admitted on an unspecified date, the MDS dated 12/13/25 documented arthritis, anxiety, and chronic pain. A nursing progress note dated 12/8/25 indicated the resident left via wheelchair with a nurse escort in baseline condition to an appointment, and a physician order dated 12/8/25 directed the resident to dose every Monday at a clinic and to receive six take-home methadone doses in a lunchbox to be administered by facility staff. The resident’s care plan, initiated on 12/8/25, failed to include any information regarding methadone use or methadone clinic appointments. In an interview on 4/4/26, the DON confirmed that the care plans for both residents did not include information concerning methadone or clinic appointments.