INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection pertaining to the plans of correction for the August 25 through August 26, 2010 methadone monitoring inspection. The follow-up inspection was conducted on April 5, 2011 by staff from the the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Pyramid Healthcare York Pharmacotherapy 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 and a plan of correction is due on May May 13, 2011.
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Plan of Correction
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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of ten patient records and an interview with the Facility Director and Doctor, the narcotic treatment program failed to have a narcotic treatment physician document whether an individual is currently physiologically dependent upon a narcotic drug for at least one year prior to admission in 1 of 5 records.
Findings:
Ten patient records were reviewed during the monitoring visit. Five patient records required documentation of a determination of dependency by the physician. There was no documentation that verified that the narcotic treatment physician made a determination of the patient's physiological dependence upon a narcotic drug for at least one year in patient record # 1.
Patient #1 was admitted on 1/18/2011. Prior to being admitted to the program the patient had completed detox and attended a drug-free inpatient treatment program for 28-days. The patient did not have a continuous one year history prior to being admitted to the program. The doctor failed to include their rationale for dosing the patient when their urinalysis was negative for opiates.
An interview with the Facility Director and program physician on April 5, 2011 confirmed this issue.
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Plan of Correction
A narcotic treatment physician will document current physiological dependence for at least one year prior to admission in all charts. In cases such as the one identified in this finding, where a physician determines this type of treatment is appropriate despite the fact that the pt. does not exhibit current physiological dependence, the physician will provide rationale on the "other" exception form, which will be submitted to the Department of Health for approval prior to admitting and treating the patient of exception.
Compliance will be monitored by random monthly medical chart audits conducted by the program director.
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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
Based on the review of patient records and an interview with the Facility Director and the doctor the facility failed to ensure that the narcotic treatment physician shall determine the proper dosage level in for four of six patients.
The findings include:
Ten patient records were reviewed on April 5, 2011. Six patient records were reviewed for the physician's documentation in determining the initial dose. Four out of six patient records, specifically,1, 2, 8, and 9 had standing orders documented for their initial dose.
Patient # 1 received an initial dose of 30 mg. Documented in patient record # 1 was an order by the physician that included a standing order to increase by 5 mg every three days until the patient reached 60 mg. There was no documentation that the narcotic treatment physician continued to assess the patient to determine if an increase in the patient's dose was needed.
Patient # 2 received an initial dose of 30 mg. Documented in patient record # 2 was an order by the physician that included a standing order to increase by 5 mg every three days until the patient reached 70 mg. May hold at any time for side effects. There was no documentation that the narcotic treatment physician continued to assess the patient to determine if an increase in the patient's dose was needed.
Patient # 8 received an initial dose of 30 mg. Documented in patient record # 8 was an order by the physician that included a standing order to increase by 5 mg every three days until the patient reached 70 mg. There was no documentation that the narcotic treatment physician continued to assess the patient to determine if an increase in the patient's dose was needed.
Patient # 9 received an initial dose of 30 mg. Documented in patient record # 9 was an order by the physician that included a standing order to increase by 5 mg every three days until the patient reached 60 mg. See again in two weeks. A standing order was documented 3/1/11 that stated to increase by 5 mg to to 85 mg. In addition, an order was written on 3/15/11 that stated to increase by 5 mg to 100 mg and an order on 3/31/2011 stated increase by 5 mg to 120 mg. There was no documentation that the narcotic treatment physician continued to assess the patient to determine if an increase in the patient's dose was needed
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Plan of Correction
The program physicians will determine the appropriate dosage level for the induction of a new client. The client will remain at this initial dose until completing a COWS assessment form.
If a client is experiencing symptoms of withdraw, they will notify nursing staff. A nurse will fill out a COWS assessment form with the client, and the form will be submitted to a program physician for review.
Upon receiving the COWS assessment, the program physicians, through assessment, will adjust dosage according to determined need. The patient will remain at the adjusted dose, until filling out another COWS if needed.
This process will continue until the patient reaches a stable dose. Each dose increase during stabilization will have a COWS form and doctor's assessment completed prior to a patient moving up in dose.
The new procedure was reviewed with the narcotic treatment physicians and nursing staff.
Compliance will be monitored by random monthly medical chart audits conducted by the program director.
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715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
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Observations
Based on a review of 10 patient records on April 5, 2011, the narcotic treatment program failed to document the narcotic treatment physician's rationale in one of two records reviewed.
The findings include:
The narcotic treatment physician failed to document the rationale for permitting take-home medication in client records # 7. Patient #7 had six day take-home privileges. She lost her privileges on 12/15/2010 because she was not attending regularly. The patients take-home privileges were reinstated on 12/7/2010. The return of the take-homes was per the counselor's rationale. The physician did not include comments or a rationale for granting the take-home privileges.
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Plan of Correction
A narcotic treatment physician will document rationale for permitting or rescinding take-home medications on all take-home request forms and all rescind take-home forms.
The change in process was reviewed with the program physicians by the program director.
Compliance will be ensured through monthly chart audits completed by the nursing staff, and random monthly medical chart audits conducted by the program director
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715.23(b)(12) LICENSURE Patient records
(b) Each patient file shall include the following information:
(12) Applicable consent forms.
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Observations
Based on the review of patient records, the consent to release information forms to the funding sources exceeded the limitations imposed at 4 Pa. Code Subsection 255.5(b) and 4 Pa. Code Subsection 255.5(a)(6) in one of six client records.
The findings include:
Ten patient records were reviewed on April 6, 2011. Six records were reviewed for consent to release information forms. Based on the review of client records, the facility failed to ensure that the information disclosed to the funding source did not exceed 4 Pa Code Subsection 255.5 (b) in record #1.
Patient record # 1 exceeded 255.5 (b) by allowing the discharge summary and aftercare to be released to the insurance company.
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Plan of Correction
This finding was the result of an error on the electronic template for this release. The release template has been revised. Program Director and Divisional Director reviewed the change with all staff and copies of old releases have been destroyed.
Releases will be reviewed for accuracy during weekly peer reviews conducted by counselors and monthly chart audits conducted by the program director.
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