INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection, conducted on March 17 - 18, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Horsham Clinic 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.
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Plan of Correction
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709.122(b)(3) LICENSURE Record of services provided.
709.122. Detoxification.
(b) Client records. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(3) Record of service provided.
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Observations
Based on a review of client records, the facility failed to document a complete client record which included a record of services provided.
The findings include:
Ten client records were reviewed on March 18, 2015, to ensure the facility documented a complete client record which included a record of services provided for each client. The facility failed to document a record of services provided in ten of ten records reviewed, # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Hospital regulations require that all services rendered are documented and substantiated by a progress note. A log will be redundant. Therefore, Horsham Clinic submitted a request for exception letter to the Department by 4/20/2015. If denied, a form documenting the record of services provided will be completed for each client record by the unit's Utilization Reviewer. The Director of UR or designee will audit 20 closed charts from each dual unit every month to ensure that the form is being completed. Results will be reviewed by the Performance Improvement Committee.
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715.9(a) 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:
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Observations
Based on a review of patient records, the facility failed to verify that individuals' have reached 18 years of age and verify the individual's identity, including name, address, and date of birth, emergency contact and other identifying data in two of six records reviewed.
The findings include:
Six narcotic treatment patient records were reviewed on March 18, 2015, to ensure the facility screened individuals prior to administration of an agent. The facility failed to verify individuals' have reached 18 years of age and verify the individual's identity, including name, address, date of birth, emergency contact and other identifying data prior to administration of an agent in records, # 3 and 7.
Patient # 3 was admitted to the program on March 8, 2015. Patient # 3 was prescribed 15 mg of methadone on March 8, 2015. The facility failed to provide documentation that patient # 3 had been screened prior to administration of an agent.
Patient # 7 was admitted to the program on January 8, 2015 and discharged on January 26, 2015. Patient # 7 was prescribed 15 mg of methadone on January 8, 2015. The facility failed to provide documentation that patient # 7 had been screened prior to administration of an agent.
The findings were reviewed with facility staff during the monitoring inspection.
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Plan of Correction
Horsham Clinic will request and photocopy drivers licenses of all patients who present for admission. If a potential patient does not have photo identification, then he/she will be asked to sign an attenstation indicating that his name, address, and date of birth are true and accurate. The Director of Admissions will audit 25 open charts each month to ensure that photo identifications or attestations are being completed. Results of audit will be reviewed by the Performance Improvement Committee. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the facility failed to obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment.
The findings include:
Six narcotic treatment patient records were reviewed on March 18, 2015, to ensure that the facility obtained an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The facility failed to obtain a consent with the required content before an agent was administered to the patient in records, #3, 4, 6, 7, 9 and 10.
Patient # 3 was admitted to the program on March 8, 2015. Patient #3 was prescribed 15 mg of methadone on March 8, 2015. The facility failed to obtain an informed, voluntary, written consent with the required content prior to being administered methdaone.
Patient # 4 was admitted to the program on March 9, 2015. Patient # 4 was prescribed 20 mg of methadone on March 9, 2015. The facility failed to obtain an informed, voluntary, written consent with the required content prior to being administered methdaone.
Patient # 6 was admitted to the program on March 10, 2015. Patient # 6 was prescribed 8 mg of buprenorphine on March 10, 2015. The facility failed to obtain an informed, voluntary, written consent with the required content prior to being administered methdaone.
Patient # 7 was admitted to the program on January 8, 2015 and discharged on January 26, 2015. Patient # 7 was prescribed 15 mg of methadone on January 8, 2015. The facility failed to obtain an informed, voluntary, written consent with the required content prior to being administered methdaone.
Patient # 9 was admitted to the program on October 15, 2014 and discharged on October 31, 2014. Patient # 9 was prescribed 20 mg of methadone on October 16, 2014. The facility failed to obtain an informed, voluntary, written consent with the required content prior to being administered methdaone.
Patient # 10 was admitted to the program on November 15, 2014 and discharged on November 19, 2014. Patient # 10 was prescribed 10 mg of methadone on November 15, 2014. The facility failed to obtain an informed, voluntary, written consent with the required content prior to being administered methdaone.
The findings were reviewed with facility staff during the monitoring inspection.
This is a repeat deficiency. The facility was previously cited for non-compliance on March 27, 2014.
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Plan of Correction
Horsham Clinic will create a medication consent form by 4/17/15 specific for the use of narcotic agents (i.e. methadone). Medical Staff will be trained in the use of the form on 4/22/15 by the Director of Quality Improvement. The Director of Quality Improvement will audit 50 closed charts per month to ensure that teh medication consent form is being utilized properly. Results of the audit will be reviewed by the Med Exec committee and the Performance Improvement Committee. |
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 a review of patient records, the facility failed to document a complete initial drug-screening urinalysis prior to the administration of a narcotic agent in six of six client records.
The findings include:
Six narcotic treatment patient records were reviewed on March 18, 2015. The facility failed to document a complete initial drug-screening urinalysis prior to the administration of a narcotic agent, in patient record # 3, 4, 6, 7, 9 and 10.
Patient # 3 was admitted to the program on March 8, 2015. The patient was prescribed 15 mg of methadone on March 8, 2015. An instant drug test was used on admission. However, the facility failed to document a complete initial drug-screening urinalysis at the time of review.
Patient # 4 was admitted to the program on March 9, 2015. The patient was prescribed 20 mg of methadone on March 9, 15. An instant drug test was used on admission. However, the facility failed to document a complete initial drug-screening urinalysis at the time of review.
Patient # 6 was admitted to the program on March 10, 2015. The patient was prescribed 8 mg of buprenorphine on March 10, 2015. An instant drug test was used on admission. However, the facility failed to document a complete initial drug-screening urinalysis at the time of review.
Patient # 7 was admitted to the program on January 8, 2015 and discharged January 26, 2015. The patient was prescribed 15 mg of methadone on January 8, 2015. An instant drug test was used on admission. However, the facility failed to document a complete drug-screening urinalysis during patient # 7's duration of treatment.
Patient # 9 was admitted to the program on October 15, 2014 and discharged on October 31, 2014. The patient was prescribed 20 mg of methadone on October 16, 2014. An instant drug test was used on admission. However, the facility failed to document a complete drug-screening urinalysis during patient # 9's duration of treatment.
Patient # 10 was admitted to the program on November 15, 2014 and discharged on November 19, 2014. The patient was prescribed 10 mg of methadone on November 15, 2014. An instant drug test was used on admission. However, the facility failed to document a complete drug-screening urinalysis during patient # 10's duration of treatment.
The findings were reviewed with facility staff during the monitoring inspection.
This is a repeat deficiency. The facility was previously cited for non-compliance on March 27, 2014.
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Plan of Correction
The Director of Nursing and Admissions will issue a memo to Medical staff, by 4/17/15, regarding the need for a lab verfied urine drug screen before initiating a narcotic agent. The Director of Nursing or designee will audit 50 closed charts of dual units each month to ensure that lab verified urine screens are being obtained prior to the initiation of a narcotic agent. Results of the audit will be reviewed by the Med Exec committee and the Performance Improvement Committee. |
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 a review of patient records, the narcotic treatment program failed to document the consultation between the narcotic treatment physicians (NTP) determining the patient's initial dose and the narcotic treatment physician (NTP) performing the physical examination in six patient records.
The findings include:
Six narcotic treatment patient records were reviewed on March 18, 2015. The facility failed to document the consultation between the NTP determining the patient's initial dose and the NTP performing the physical examination, in patient record # 3, 4, 6, 7, 9, and 10.
Patient # 3 was admitted to the program on March 8, 2015. The patient was prescribed 15 mg of methadone on March 8, 2015 by a doctor that was not identified or reported as an NTP. In addition, the patient's physical exam was completed March 9, 2015 by a doctor that was not identified as an NTP. The facility failed to verify or document a consult between the two non-NTP doctors before patient # 3 was prescribed medication.
Patient # 4 was admitted to the program on March 9, 2015. The patient was prescribed 20 mg of methadone on March 9, 15 by an NTP; however, the facility failed to verify or document a consult between the NTP and the non-NTP doctor that completed the patient's physical examination on March 10, 2015 after the patient was prescribed medication.
Patient # 6 was admitted to the program on March 10, 2015. The patient was prescribed 8 mg of buprenorphine on March 10, 2015 by a doctor that was not identified or reported as an NTP. In addition, the patient's physical exam was completed on March 10, 2015 by a doctor that was not identified as an NTP. The facility failed to verify or document a consult between the two non-NTP doctors before patient # 6 was prescribed medication.
Patient # 7 was admitted to the program on January 8, 2015. The patient was prescribed 15 mg of methadone on January 8, 2015 by a doctor that was not identified or reported as an NTP. In addition, the facility failed to provide documentation of a physical examination for patient # 7 as of the time of review on March 18, 2015.
Patient # 9 was admitted to the program on October 15, 2014. The patient was prescribed 20 mg of methadone on October 16, 2014 by a doctor that was not identified or reported as an NTP. In addition, the same prescribing non- NTP doctor completed patient # 9's physical exam.
Patient # 10 was admitted to the program on November 15, 2014. The patient was prescribed 10 mg of methadone on November 15, 2014 by a doctor that was not identified or reported as an NTP. In addition, the patient's physical examination was completed by a doctor that was not identified as an NTP. The facility failed to verify or document a consult between the two non-NTP doctors before patient # 11 was prescribed medication.
The findings were reviewed with facility staff during the monitoring inspection.
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Plan of Correction
Horsham Clinic failed to submit a complete list of NTPs on its methadone questionnaire. Only NTPs prescribe narcotic agents at The Horsham Clinic. Horsham will submit a complete list of all NTP during prior to the next annual inspection. In addition, if the examining NTP and the initial prescribing NTP differ, the initial prescribing NTP will consult with the examining NTP and both will co-sign the initial order. Medical record staff will audit all the closed dual charts to ensure the co-signing of initial orders. Results of audit will be reviewed by the Performance Improvement Committee. |