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 September 18, 19, and 20, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House CU, Inc. 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 October 11, 2007.
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Plan of Correction
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715.6(b)(1-9) LICENSURE Physician Staffing
(b) A narcotic treatment program may employ narcotic treatment physicians to assist the medical director. A narcotic treatment physician 's responsibilities include:
(1) Performing a medical history and physical exam.
(2) Determining diagnosis and determining narcotic dependence.
(3) Reviewing treatment plans.
(4) Determining dosage and all changes in doses.
(5) Ordering take-home privileges.
(6) Discussing cases with the treatment team.
(7) Issuing verbal orders pertaining to patient care.
(8) Assessing coexisting medical and psychiatric disorders.
(9) Treating or making appropriate referrals for treatment of these disorders.
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Observations
The facility failed to include the required duties of a narcotic treatment physician in their policy and procedure manual; specifically, the policy and procedure did not include:
2) Determining dosage and narcotic dependence,
5) Ordering take-home privileges,
6) Discussing cases with the Treatment Team,
7) Issuing Verbal Orders,
8) Assessing coexisting medical and psychiatric disorders, and
9) Treating or making appropriate referrals for treatment of these disorders.
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Plan of Correction
Policy will be reviewed and amended/changed/purged as needed. Director and Policy Advisor from DH HO will be responsible. |
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 patient's previous narcotic treatment program to request information for patients #13 and 18.
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Plan of Correction
The clinical supervisor will conduct in-service trainings to ensure the facility will contact patient's previous MMTP programs to aquire all their past histories. The clinical supervisor will monitor through chart reviews. The program director will oversee. |
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
The facility failed to remove or conceal patients' names on patient take home bottles that were returned to facility. The returned bottles were discarded into the trash with patient names visible; said action compromised the confidentiality of facility patients who received take home bottles. This noncompliance was determined by observation and confirmed by staff interviews.
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Plan of Correction
The program director will conduct in-service for the medical associates to ensure that all takehome bottles being returned will have their names crossed off prior to putting them in the trash. The program director will monitor to ensure compliance. |
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
The facility failed to document that drug screening would occur at least monthly. Current policy identified that drug testing is done "eight times per year and or as required by state regulations, whichever is greater".
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Plan of Correction
Policy will be reviewed and amended/changed/purged as needed. Director and Policy Advisor from DH HO will be responsible. |
715.15(d) LICENSURE Medication dosage
(d) A narcotic treatment program shall label all take-home medication with the patient 's name and the narcotic treatment program 's name, address and telephone number and shall package all take-home medication as required by Federal regulation.
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Observations
The facility failed to provide written take home policies and procedures that are consistent with their current practice. Specifically, current facility policy stated that a patient with six day take home privilege would have solid form take homes in a single labeled container. The facility's practice is to provide a single labeled container for each day to their patients with six day take home status.
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Plan of Correction
Policy will be reviewed and amended/changed/purged as needed. Director and Policy Advisor from DH HO will be responsible. |
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 failed to address in policy and procedure the requirement that during the administration of medication only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
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Plan of Correction
Policy will be reviewed and amended as needed. Director and Policy Advisor from DH HO will be responsible. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
The facility failed to include information on the patient's legal standing and employment status in the annual evaluation for patients # 4 and 16.
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Plan of Correction
An in-service will be held by the clinical supervisor to ensure that all areas are included in the annual evaluations. The clinical supervisor will monitor compliance through chart audits. The program director will oversee to ensure compliance. |
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 identify tasks to be performed by the patient when working on treatment plan goals. The short term goals are written to provide interventions by the counselor but lacked the specific tasks to be performed by the patient. This pattern was identified in fifteen of fifteen patient charts reviewed for treatment goal content.
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Plan of Correction
The clinical supervisor will conduct in-service trainings on treatment plan goals to include tasks to be performed by the patient. The program director will monitor to ensure compliance. |
715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
The facility's policies and procedures failed to include the required reasons that necessitated an incident report. The policies and procedures did not include: complaints of patient abuse, disruption of services, negative community impact, and drug related hospitalization of a patient.
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Plan of Correction
Policy will be reviewed and amended/changed as needed. Director and Policy Advisor from DH HO will be responsible. |
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 six day take-home privileges. Patients on six day status based on the 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 #15, 16, and 18.
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Plan of Correction
The program director will conduct an in-service for all medical associates to ensure that quarterly call backs are being conducted. The Program director will monitor to ensure compliance. |