INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use narcotic agents, specifically methadone and buprenorphine in the treatment of narcotic addiction. This inspection was conducted on May 3 through May 5, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House HA was found not to be in compliance with the applicable chapters of 4 PA Code and 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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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 February, March and April were reviewed on May 3, 2011. There were insufficient onsite physician hours during February, March, and April.
During the week of February 27- March 5, 2011, the census was 476 patients and 43.09 physician hours were provided during this time frame.
During the week of March 20 -March 26, 2011, the census was 476 patients and 46.02 physician hours were provided during this time frame.
During the week of March 27 - April 2, 2011, the census was 476 patients and 39.68 physician hours were provided during this time frame.
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Plan of Correction
The Program Director will hold training within 7 days for the narcotic physicians, physician assistances, and CRNP explaining the importance of providing sufficient physician hours in keeping with Pennsylvania regulations. Program Director to complete the schedule on a weekly basis and review mid week to ensure hours are obtained. The Program Director will monitor and this will be in effect 5/18/11. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on a review of administrative documentation and an interview with the facility director, the facility failed to ensure the photo identification maintained onsite was updated every three years as required.
The findings include:
The facility policy and procedure manual was reviewed on May 3, 2011. The facility policy did not include how the patient photo identification would be updated in the records every three years as required by the standard. An interview with the facility director took place on May 3, 2011 at 11:45 a.m. At 12:10 p.m. the facility director confirmed that there is no way to know when to update a patient photo in the computer system.
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Plan of Correction
Patient photo's will be updated every 3 years and will be documented via a general note by clinical staff. Clinical Staff to be provided a brief training on how to update photographs on the software. Director will complete quarterly audits to ensure compliance. This will take effect as of 5/18/11. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on the review of patient records and an interview with the facility director, the narcotic treatment program failed to document the results of annual reevaluations by the narcotic treatment physician ten of ten patient records.
The findings include:
Twenty-six patient records were reviewed on May 3- 5, 2011. Annual reevaluations by the narcotic treatment physician were required in ten patient records. The narcotic treatment program failed to document the results of the annual reevaluation by the narcotic treatment physician in patient records # 5, 6, 7, 8, 10, 15, 22, 23, 24, 25, and 26. The annual physical exams were completed by the Certified Registered Nurse Practitioner in these records. The Narcotic Treatment Physician did include a statement that said, "Annual review and physical exam done by midlevel provider reviewed." However, the narcotic treatment doctor failed to document and indicate whether or not the patient should remain in methadone maintenance treatment.
This is a repeat citation from the methadone monitoring inspection conducted on July 20- 22, 2010. According to the plan of correction approved on 8/26/2010, " The Medical Director will document via a medical note that he evaluated the annual review and physical and will document his determination whether the patient should continue MMT or begin an MSW. Program Director to provide training on this process. This will take place within 30 days. Program Director will conduct quarterly chart reviews to ensure this task is completed."
The facility director confirmed this finding and agreed that the doctor was not including his determination in the medical note that was written.
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Plan of Correction
A training was provided by the Program Director to the Medical Director and Physician on documentation of the annual review and physical. The training focused on the review of mid level physical exam and documentation of the service to include the Physicians plan of continued methadone maintenance or withdrawal from treatment. The program Director and Program Manager will conduct monthly reviews to ensure compliance. This will take effect on 5/18/11 |