INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use a narcotic agent, specifically methadone, in the treatment of narcotic addiction. This inspection was conducted on December 13, 14, and 15, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Habit Opco, Inc. was found not to be compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and a plan of correction is due on January 11, 2011.
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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
Based on the review of administrative documentation, the facility failed to provide at least one hour of physician time a week, on site for, every ten patients.
The findings include:
Physician time sheets and and census reports for the months of August, September, October, and November were reviewed on December 13, 2010. There were insufficient onsite physician hours during August, September, and November.
During the week of August 1-7, 2010, the census was 171 patients and the facility provided 9.5 physician hours.
During the week of August 8-14, 2010, the census was 171 patients and the facility provided 15 physician hours.
During the week of September 19-25, 2010, the census was 184 patients and the facility provided 13.5 physician hours.
During the week of November 21-27, the census was 187 patients and the facility provided 11 physician hours.
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Plan of Correction
An additional narcotic treatment physician has been hired to provide coverage for when the Medical Director is unavailable. This physician will provide adequate coverage as needed, such as for an illness of the Medical Director, and vice versa.
The Program Director has met with the Medical Director to discuss the shortage of hours and to develop a plan for coverage. The Medical Director will provide at least one month's notice of any planned time off so that additional coverage can be arranged. The Program Director and the Medical Director reviewed all scheduled holidays for the year and have rearranged the doctor's schedule in order to ensure that physician coverage will be available.
The Medical Director and the Nurse Manager will provide a monthly schedule of physician coverage for the coming month by the 15th of each month. This schedule will be reviewed by the Program Director for approval. Annually, the list of scheduled holidays and any planned time off will be reviewed in January in order to arrange needed coverage.
In addition, the Program Director will inform the Medical Director of any change in census on a weekly basis, and the physician hours will be adjusted accordingly. |
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
Based on the review of patient records, the facility failed to contact the previous facility for the patient's treatment history in two of three patient records reviewed.
The findings include:
Twenty-four patient records were reviewed December 13-15, 2010. Three patient records required contact with prior treatment facilities for the treatment history. Patient records #1 and 6 did not have documentation of any attempt to obtain the patient's prior treatment history from prior treatment facilities.
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Plan of Correction
At the general staff meeting on January 7, 2010, the Program Director will review the relevant regulation with all staff, and will review the process as described below. At the group supervision meeting on January 6, 2010, the Clinical Director will discuss the relevant regulation with the clinical staff, who are responsible for obtaining the initial history and required consent to release information.
The clinical staff will be advised to obtain a consent from any patient who reports previous treatment and can provide the name and approximate address. If the patient cannot provide the name and location of their previous treatment, the clinician will note this in the intake note. The clinician will attempt to identify the previous treatment facility and will contact that facility to request the treatment records. The clinician will then document the contact in the case history and will file the records and any relevant consent in the patient's chart.
The Clinical Director will monitor this process monthly for the next three months to ensure that the clinical staff is following the procedure. |
715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
Based on the review of patient records, the facility failed to maintain the confidentiality of patient information in accordance with 42 CFR and 4 PA Code 255.5 in five of eighteen patient records.
The findings include:
Twenty-four patient records were reviewed on December 13-15, 2010. Eighteen records were reviewed for the content of signed consents to release information. Six records contained documentation of consents to release information that exceed 4 PA Code 255.5.
Patient record # 8 contained a document that was released to someone by the name of Rich; however, there was no consent to release in the patient file for anyone by that name.
Patient record # 11 contained a consent to release to for Medical Assistance. The release form did not document the specific information that was going to be released.
Patient record # 15 contained a consent to release dosing information to the billing agency.
Patient record # 16 contained a consent to release that indicated urine results would be released to the probation officer.
Patient record # 22 contained a consent to release to allow the Department of Public Welfare to have the patient's dose and prescription verification.
This is a repeat citation from the monitoring visit held on April 21-22, 2010.
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Plan of Correction
At the general staff meeting in January the Program Director and Clinical Director will devote half the meeting to the correct process for completing consents to release information. Handouts shall be provided, but will not be limited to "Chapter 255: Management Information, Research and Evaluation" from the PA Department of Health, and "Frequently Asked Questions" regarding confidentiality from the Legal Action Center and SAMHSA.
The staff will individually view the Habit OPCO powerpoint presentation on confidentiality by the end of January 2011.
For two months following the staff meeting, the Nurse Manager, Clinical Director and Program Director will review a random sample of at least 10% of the patient charts for correct completion of consents. The Nurse Manager, Clinical Director and Program Director will each meet with her supervisees to ensure that any incorrectly completed consents are redone correctly.
The records cited in this citation will be reviewed with the person who completed the consent or other record incorrectly to ensure that the staff person understands the error.
The Program Director and Clinical Director will continue to randomly review consents for two additional months to ensure that the documentation is correct. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on the review of patient records, the facility failed to provide urine drug test results in four of twenty patient records.
The findings include:
Twenty-four patient records were reviewed on December 13-15, 2010. Twenty patient records were reviewed for urinalysis results. Patient records # 15, 16, 18, and 21 failed to have results posted as follows:
Patient record # 15 failed to have results for urinalysis that was conducted in November 2010.
Patient record # 16 failed to have results for urinalysis that was conducted in July and November 2010.
Patient record # 18 failed to have results for urinalysis that was conducted in July 2010.
Patient record # 21 failed to have results for urinalysis that was conducted in July 2010.
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Plan of Correction
The Program Director will present discuss this citation at the general staff meeting in January. The Habit OPCO policy regarding urinalysis results will be reviewed, and the staff will be informed of the specific expectation that any missing information is to be obtained by the primary counselor within 15 working days of the date the urine sample was obtained.
The Clinical Director and Nurse Manager will each then randomly check at least 10 times per month for two months to ensure that the information has been obtained and properly recorded. |
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
Based on observation and staff interview, the facility failed to ensure only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
The findings include:
On December 13, 2010, patients were observed in the dosing are. Staff and patient interviews identified and confirmed the facility's failure to prohibit only those dosing access to the dispensing area.
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Plan of Correction
At the general staff meeting in January, the Program Director will review the relevant regulation with all staff. The Program Director will also address the regulation in a written memo to security staff and separately, to patients.
The Nurse Manager will ensure that the dispensing staff instruct any patient who enters the dosing area with an unauthorized person that they will not be medicated under those circumstances, and the unauthorized person(s) will be required to leave the area. The Program Director will provide the same instruction to the front desk and security staff. The Clinical Director will review the regulation with the counselors at the next group supervision meeting and the counselors will be instructed to inform their patients of the regulation.
The Program Director and Nurse Manager will monitor compliance daily for two weeks to ensure that the regulation is being correctly followed. |