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 February 20, 21, and 22, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Directions was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on March 25, 2008.
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Plan of Correction
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715.9(a)(3) 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:
(3) Obtain a drug use history and current drug use status of the individual.
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Observations
A review of eleven randomly selected patient records revealed that the facility failed to obtain the initial urinalysis results prior to the initial dose; specifically, patients 14 and 17.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
In a review of 14 randomly selected patient records, the facility failed to, with patient consent, contact the previous narcotic treatment facility for the patient's treatment history. Specifically, patient records # 5, 23 and 24 did not contain documentation that prior treatment programs had been contacted for patient records nor were there records from prior narcotic treatment included in the patient record.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
715.16(c) LICENSURE Take-home privileges
(c) A narcotic treatment program shall require a patient to come to the narcotic treatment program for observation daily or at least 6 days a week for comprehensive maintenance treatment, unless a patient is permitted to receive take-home medication as follows:
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Observations
The facility failed to submit an exception request to the Department of Health for the consideration of thirteen day take home privileges for patient # 21. All considerations for patients to receive 13 day take home privileges must be submitted to the Department of Health prior to implementation.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
715.16(e) LICENSURE Take-home priveleges
(e) With an exception granted under subsection (d), a narcotic treatment program may not permit a patient to receive more than a 2-week take-home supply of medication.
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Observations
The facility failed to comply with the Department of Health's denial of a request for thirteen day take home privileges for # 10. Specifically, a request for thirteen day take home privileges for patient #10 was submitted to the Department of Health on February 28, 2007 and it was denied. Records indicated the physician ordered 13 day take home privileges for patient # 10 on March 15, 2007; there was no documentation of approval by the Department of Health.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 review of 18 randomly selected patient records and interviews with the medical staff, the facility failed to ensure the physician was the person determining patient doses, but rather has allowed other staff, particularly nursing staff, to write the orders with the physician signing them.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
The facility failed to provide all required information to the receiving facility in 1 of 2 patient records. Specifically, patient # 8 was transferred to another facility; New Directions did not provide the new facility with documentation of psychosocial summaries and current status.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
715.21(1)(i-iv) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
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Observations
The facility failed to restrict the policy and procedure on patient termination to the reasons addressed in the regulations. The facility permitted: failure to meet medical requirements, second offense for urine tampering, arrest for illicit sales following admission, falsification/forgery, and bribing or intimidating staff to tamper with urine specimens as reasons to terminate the patient from treatment.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
715..23(b)(1) LICENSURE Patient records
(b) Each patient file shall include the following information:
(1) A complete personal history.
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Observations
Based on a review of eleven randomly selected patient records, the facility failed to document complete personal histories for patients #2, 4, 24 and 26 as they contained one word responses that failed to provide clarification of significant issues that were identified during the interview/information collection process.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
Based on a review of thirteen randomly selected patient records, the facility failed to complete timely lab testing for patients # 5 (admitted on 11/28/07, patient did not have blood serology test completed until 2/7/08) and #14 (admitted on 1/23/08, patient did not have a blood serology test until 2/7/08).
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on a review of thirteen randomly selected patient records, the facility failed to complete psychosocial evaluations within their stated policy of one week, specifically, patients # 4 and 5 and 17 had evaluations that were completed later than one week after admission. Additionally, patient # 14 did have a completed psychosocial evaluation (admit date 1/23/08) as of February 21, 2008.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
715.23(d)(1) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(1) The treatment plan shall identify the behavioral tasks a patient shall perform to complete each short-term goal.
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Observations
The facility failed to develop treatment plans that contained short term goals with measurable steps. Further, the treatment plans failed to identify support systems needed by the patient. Of the the nine patient records reviewed, patient records # 5, 23, and 24 did not contain measurable tasks to be completed by the patient to accomplish the short term goals.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
715.23(d)(2) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Based on a random review of patient records, the facility failed to document patient progress or lack of progress in achieving their treatment goals from the prior treatment plan in five of ten patient records reviewed, # 1, 3, 16, 18 and 24.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on review of administrative documentation provided during the inspection and staff interviews, the facility's internal incident report file contained documented incidents that required submission to the Department. The facility failed to submit documentation of unusual incidents as required.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
715.29(5) LICENSURE Exceptions
A narcotic treatment program is permitted, at the time of application or any time thereafter, to request an exception from a specific regulation.
(5) If the exception relates to a specific patient, the narcotic treatment program shall maintain documentation of the exception in the patient 's record.
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Observations
The facility failed to comply with the conditions of the exception granted by the Division regarding thirteen day take-home privileges. Patients on thirteen day take-home status based on this exception must have quarterly call backs (an unscheduled return to the facility within 24 hours) that includes an inventory of patient's remaining take-home supply and drug testing or methadone plasma levels. The facility failed to conduct quarterly call backs for patients # 10 and 21.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |