INITIAL COMMENTS
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This report is a result of an onsite licensure renewal and methadone monitoring inspection. The inspection was conducted on March 21 - 23, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite inspection, Hanover Treatment Services 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 the inspection:
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Plan of Correction
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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
The facility failed to obtain an informed and voluntary consent from the client. The release of information form for another provider did not indicate the purpose for disclosure in patient record #2. The release of information form for a funding source was not documented in patient records #4, and #5. This was discussed with the facility staff during the inspection process.
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Plan of Correction
A staff meeting with all staff was held on Monday, March 27. During the meeting staff were re-trained on how to properly fill out a release of information form including that the release must state the purpose, (ex. Coordination of Care)
Moving forward, all new employees will be trained during orientation on documentation procedures by the Facility Director.
In patient records #4 and #5, the funding source was an out of county source that we do not contract with or bill. We have amended our intake procedure to request a release of information for a current out of county or non-contracted funding source on all patients who have such a source at admission. Additionally, we have gone back through our current patients to insure that every patient file has an appropriately filled out and signed release of information for that patients funding source.
Facility Director will monitor for compliance during weekly chart audit process.
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709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
The facility physician failed to authenticate verbal orders in writing in patient record #1, 2, 3, 4 and 5. Verbal orders were given by the physician in all records reviewed. Verbal orders were not signed by the physician in records #1, 2 and 3, and were not signed by the physician within three business days in records #4 and 5. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A re-training for our medical staff, Doctors and nurses, was conducted on Thursday, March 23rd, Friday, March 24th and Tuesday, March 28th to review the procedure for where to locate the unsigned verbal orders within our EMR system, SMART, how to review, acknowledge and sign the orders and the necessity of all orders being signed within 72 hours of being given.
The nursing staff prints out the verbal orders daily to check for signatures and ensure the doctor is signing off electronically. After the nurses review the form, note orders have been signed, the form is given to the Facility Director to ensure completeness.
Effective 3-28-17, one of the program physicians hours have been adjusted to insure we have a physician on site often enough to review, acknowledge and sign any verbal orders given within the 72 hour time frame.
Moving forward, all new employees will be trained during their orientation on medication control by the Facility Director.
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715.9(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
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Observations
The facility failed to contact the two previous treatment facilities for the treatment history in patient record #2. This was discussed with the facility staff during the inspection process.
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Plan of Correction
A re-training with all staff was held on Monday, March 27th to review intake procedures and documentation required during the intake process. Staff were retrained to seek a voluntary release of information for any previous narcotic treatment program(s) the admitting patient had attended.
Moving forward, all new employees will be trained during their orientation on intake procedures by the Facility Director.
Facility Director conducts weekly chart audits and will monitor for compliance.
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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
The facility physician failed to document the rational for permitting take home privileges for patient #4 and #5.This was discussed with the facility staff during the inspection process.
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Plan of Correction
Documentation of the rationale for physician granting take home privileges has been added to the record for patient # 4 and patient #5.
The facility uses the SMART EMR system which contains a format for the physician to document criteria and rationale for take home bottle privileges.
Re-training on the use of the form was provided to our doctors on Friday, March 24 and Tuesday, March 28. All clinical and nursing staff were retrained on take home bottle procedures during the all staff meeting held Monday, March 27.
Take home justification for potentially eligible patients will be addressed during weekly treatment team meetings prior to any take home bottle privileges being granted.
Moving forward, all new employees will be trained during their orientation on take home procedures by the Facility Director.
Facility Director will monitor compliance through weekly chart audits and attendance at treatment team meetings.
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715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
The facility physician failed to determine the dose and schedule, document the medication order, and the facility failed to administer the medication according to the medication order . 1. The medication order did not include the dose and schedule in patient records # 1, 2, 3, 4, and 5. 2. In record #2, the patient last dosed 80 mg on 2-9-17, and was AWOL until 2-16-17. The patient was dosed 30mgs on 2-16-2017. A medication order for 2-16-2017 was not documented.3. In record #2, the medication dose given on 2-16-2017 was determined by staff other than the physician. 4. Patient record #3 included a 2-28-2017 medication order which stated, "Inducing at 30mg. will increase by 10 mg as per protocol as needed".5. The facility failed to administer the medication according to the medication order. Patient # 3 was administered 25mg of medication on 3-1-2017. The medication order documented the dose to be 30 mg.This was discussed with the facility staff during the inspection process.
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Plan of Correction
1. Medical staff, physicians and nurses, were retrained on March 24 and again on March 28 to include the dose and schedule in the notation section for every medication order.
Facility Director will monitor for compliance through weekly chart audits.
2. and 3. Patient #2 was incarcerated during the period of absence from the facility. The staff involved, a nurse and a counselor, were counseled, given copies of and retrained on our policy regarding patients put on inactive status. Staff involved were specifically counseled that only the medical director or his/her designee can make the determination of whether to administer medication and at what dose and frequency.
Refresher training on medication administration related policies and procedures was conducted as part of the all staff meeting on March 27.
4. Facility Director met with program physician on March 28 to review this order. Program physician received training on writing orders that include the dose and schedule and the need for a separate order each time there would be an adjustment to the dose or schedule.
5. The facility uses an automatic dispensing system which administers the current dose. At the time this dose was administered, the order was for 25 mg. The order to change to 30 mg happened after patient #3 had already dosed. The order was incorrectly dated and should have reflected the increase to take effect at the next dose on 3-2-2017. Facility Director reviewed this order with both the nurse and program physician involved.
Moving forward, all new employees will be trained during their orientation on dosing procedures by the Facility Director.
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715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
The facility failed to document, in writing, that it notified the transferring narcotic treatment program of the admission of the patient and the initial dose given in patient records #3 and #4.This was discussed with the facility staff during the inspection process.
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Plan of Correction
A patient transfer acknowledgement form which includes admission date and date and amount of initial dose was developed for use within our SMART EMR system. Staff were retrained on the use of the form during the all staff meeting held 3-27-17. Facility Director will monitor for compliance during weekly chart audit process.
Moving forward, all new employees will be trained during their orientation on patient transfers by the Facility Director.
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