INITIAL COMMENTS
|
This report is a result of an off-site unusual incident investigation conducted on March 31, 2023, and April 3, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the off-site investigation, Avenues Recovery Medical Center 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:
As this was an offsite unusual incident investigation, not all regulations were reviewed.
|
Plan of Correction
|
715.9(a)(4) 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:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
|
Observations
The narcotic treatment program failed to have a narcotic treatment physician make a face- to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient ' s record the basis for the determination of current dependency and evidence of a 1-year history of addiction.
Patient #1 was admitted on March 12, 2023 and discharged on March 15, 2023. Patient #1 was administered an agent on March 12, 2023, and a face-to-face determination with the narcotic treatment physician did not occur until March 13, 2023.
These findings were reviewed with program staff during the investigation process.
|
Plan of Correction
The Medical Director and Nurse Executive, under the authority of the Quality Assurance and Performance Improvement Committee, will have responsibility to ensure the completion of the following corrective action steps:
1. The Medication Assisted Treatment Policy will be reviewed, updated, and implemented to include the following expectations: (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: (4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
2. The Medical Director and Nurse Executive will monitor compliance with the above policy and document corrective action as appropriate.
3. Monitoring and corrective action will be reported to the Quality Assurance and 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.
|
Observations
The narcotic treatment program failed to obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment in one patient record reviewed.
Patient #1 was admitted on March 12, 2023 and discharged on March 15, 2023. The narcotic treatment program failed to obtain an informed, voluntary, written consent before administering buprenorphine on March 12, 2023.
This is a repeat citation from the February 27, 2023 - March 1, 2023 licensing inspection.
These findings were reviewed with program staff during the investigation process.
|
Plan of Correction
The Nurse Executive, under the authority of the Nursing Leadership Committee and Clinical Governance Committee, will have responsibility to ensure the completion of the following corrective action steps:
1. The Medication Assisted Treatment Policy, Medication Administration Policy, and First Dose Verification Policy will be reviewed, updated, and implemented to ensure that informed consent is obtained and documented according to hospital, payor, and regulatory requirements and expectations, to include the following expectations:
a. The hospital will obtain informed, voluntary, and written consent prior to the administration of methadone and buprenorphine
b. The consent form will include the following information: (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.
2. The Nurse Executive will monitor compliance with the above policy and document corrective action as appropriate.
3. Monitoring and corrective action will be reported to the Nursing Leadership Committee and Clinical Governance Committee.
|
711.52(e) ELEMENT Provision of services
711.52. Treatment and rehabilitation services.
(e) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of one client record, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan.
Client #1 was admitted on March 12, 2023 and discharged on March 15, 2023. An individual treatment and rehabilitation plan was developed with the client on March 12, 2023, that indicated individual sessions two times a week and group daily. The client record only included one group session on March 14, 2023, no other documentation of was listed from the client ' s date of admission to date of discharge.
These findings were reviewed with facility staff during the investigation process.
|
Plan of Correction
The Director of Counseling, at the direction of the Support Services Governance Committee, will have responsibility to ensure the completion of the following corrective action steps:
1. The Counseling Services Policy will be reviewed, updated, and implemented to ensure that counseling sessions are ordered, scheduled, and documented according to hospital, payor, and regulatory requirements and expectations, to include the following expectations:
a. Counseling staff shall complete an initial Bio-Psycho-Social Assessment within 72 hours of admissions
b. Initial treatment plan and counseling session shall be completed within 72 hours of admissions
c. Treatment plans shall include 1 individual counseling session per week and 7 group counseling sessions per week.
d. Staff are required to document patient refusal to participate in counseling sessions, including group sessions.
e. Staff shall be held accountable for failure to document refusal to participate in sessions
2. Director of Counseling will monitor compliance with the above policy and document corrective action as appropriate.
3. Monitoring and corrective action will be reported to the Support Services Governance Committee. |