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 March 16-18, 2010 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 4 PA Code and 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on April 13, 2010.
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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 time sheets, census reports and an interview with the facility director, the facility failed to provide at least one hour of physician time per week on site for every ten patients.
The findings include:
Physician time sheets and and census reports for the months of November, December, January, February and March 1-13, 2010 were reviewed on March 16-18, 2010 . There were insufficient onsite physician hours during December 2009 and March 2010.
During the week of December 1, 2009, the census was 383, the total physician hours documented was 30 hours.
During the week of January 11, 2010, the census was 386, the total physician hours documented was 37.77 hours.
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Plan of Correction
The Program Director will hold training within 30 days for the narcotic physicians and physician assistances explaining the importance of providing sufficient physician hours in keeping with Pennsylvania regulations. The Program Director will monitor twice weekly for compliance. |
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
Based on the review of patient records and an interview with the facility director, the facility failed to contact the previous facility for the patient's treatment history in one of three patient records reviewed.
The findings include:
Nineteen patient records were reviewed March 16-18, 2010. Three patient records were required to provide documentation that attempts had been made to contact prior treatment facilities for treatment information. Patient record #12 did not contain documentation of an attempt to obtain the patient's prior treatment history from prior treatment facilities.
In patient record # 12, the patient had signed a consent to release information to obtain the patient's history from the previous facility. There was no documentation of the patient's previous history in the patient record. Additionally, there was no documentation in the patient's record that showed the facility had requested the information.
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Plan of Correction
The Program Director and Clinical Supervisor will hold training within 30 days with the clinical staff explaining the regulatory requirements for obtaining records from previous facilities for the treatment records. Training will include information on signing releases and appropriate documentation that the information was requested The clinical supervisor will follow-up as needed in individual supervision.
The Clinical Supervisor will be responsible for monitoring compliance using the scheduled quantitative review of each patient chart. The Program Director will do sporadic checks to ensure compliance.
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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
Based on a review of patient records and an interview with the facility director, the facility failed to maintain confidentiality of patient records in accordance with 42 CFR 2.22 and in three of seventeen patient records.
The findings include:
Nineteen patient records were reviewed on March 16-18, 2010. Seventeen were reviewed for compliance with the confidentiality of patient records. The facility failed to comply with this requirement in patient records # 2, 4 and 8.
In patient record # 2, a progress note dated 2/11/2010 revealed that urinalysis drug screen (UDS) results had been sent to the patient's probation officer. The information exceeded that which is permitted under 42 CFR 2.22 and 709.28.
In patient record # 4, the patient record contained a letter from a human service agency that included a request for urinalysis drug screen (UDS) results. Patient record # 4 contained documentation of signed consent to release the patient's UDS results to the human service agency. The information exceeded that which is permitted under 42 CFR 2.22 and 709.28.
In patient record # 8, the patient's dose amount was released to a hospital on February 26, 2010. There was no consent to release information for the hospital in the patient's record.
The facility director was interviewed on March 18, 2010. The facility director confirmed the consents to release were not documented in the patient's record.
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Plan of Correction
The Clinical Supervisor conducted a training on 4/1/10 to address confidentiality of all patient records in accordance with 42 CFR 2.22, The training included a review of regulatory requirements regarding patient information and the release of information with outside entities. The clinical supervisor addressed the limitations under Pennsylvania regulations. A second training will be scheduled and will be mandatory, the training will be conducted by the Executive Clinical Director explaining 42 CFR and HIPPA. This will also be addressed in individual supervision.
The Clinical Supervisor will review information to be released to outside entities. The Program Director will do sporadic checks to monitor compliance.
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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 review of the patient records, the facility failed to obtain a complete urine drug screen urinalysis prior to the administration of methadone, a narcotic agent in one of eight patient records.
The findings include:
Nineteen patient records were reviewed on March 16-18, 2010. Eight patient records were reviewed for compliance with the requirement to complete an initial drug screen urinalysis prior to the administration of methadone, a narcotic agent. A complete urine drug screen includes receiving the results from the CLIA and Department of Health approved laboratory. The facility failed to obtain a complete urine drug screen urinalysis prior to the administration of methadone in patient record # 10.
Patient # 10 was admitted on January 25, 2010. The urine drug screen results were made available to the facility on January 27, 2010. The dosing records document the first dose of methadone was given to the patient on January 25, 2010.
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Plan of Correction
The Program Director will hold a medical training on 4/14/10 to review regulations that require that we receive the results of the urine drug screen prior to medicating the patient. Transfer patients will be courtesy dosed until the urine drug screen results are posted. The Program Director will be responsible to monitor for compliance. |
715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
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Observations
Based on the review of patient records and an interview with the facility director, the facility failed to document the physicians's rationale for permitting take-home medication in two of eight patient records.
The findings include:
Nineteen patient records were reviewed on March 16-18, 2010. Eight patient records were required to have documentation of the narcotic treatment physician's rationale for permitting take-home medication. Patient records # 3 and 5 failed to contain documentation of the physician's rationale for determining take-home medication privileges.
In patient record # 3, an order, dated February 4, 2010, rescinded the patient's take home privileges. Documentation indicated that the patient resumed take-home privileges on February 24, 2010. There was no documentation of the physician's rationale in the patient record permitting the patient to resume take-home medication privileges on February 24, 2010.
In patient record # 5, the patient was permitted triweekly take-homes. There was no documentation in the patient's record of the narcotic treatment physician's rationale for permitting take-home medication.
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Plan of Correction
The Program Director will hold a medical training 4/6/10 with the Medical Director to review regulatory requirements for documenting the physicians' rationale for granting take home medications. The Program Director will check take home orders to ensure the rationale is documented. |
715.16(a)(5) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(5) A narcotic treatment program shall develop written policies and procedures relating to granting and rescinding take-home medication privileges.
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Observations
Based on the review of the policy and procedure's manual and the facility's form "PA Take home Privilege Eligibility Information", the facility failed to consider their policies and procedures relating to granting and rescinding take-home medication privileges as the referred to form is inconsistent with facility policy and regulations.
The findings include:
The facility's policy and procedure manual and the "PA Take home Privilege Eligibility Information" form were reviewed on March 16, 2010. The policy and procedure manual was consistent with the regulations and indicated the narcotic treatment physician must grant and rescind take-home medication privileges. The facility failed to follow the documented policy and procedures and regulations when they informed patients in writing of the criteria for take-home privileges. The facility provided each patient at admission with a "PA Take home Privilege Eligibility Information" form. The form stated "it will be the decision of the clinical staff to remove totally or partially any take-home privileges-either on an emergency measure or following a meeting with the patient, counselor and clinical staff".
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Plan of Correction
The Program Director is responsible to have all forms consistent with the Pa regulation and the facility policy. The "PA Take home Privilege Eligibility Information" form was revised on 3/31/10 and no longer states "it will be the decision of the clinical staff to remove totally or partially any take-home privileges-either on an emergency measure or following a meeting with the patient, counselor and clinical staff". It is the sole responsibility of the Medical Director to rescind or grant take homes.
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715.16(b)(1-8) LICENSURE Take-home privileges
(b) The narcotic treatment physician shall consider the following in determining whether, in exercising reasonable clinical judgment, a patient is responsible in handling narcotic drugs:
(1) Absence of recent abuse of drugs (narcotic or non-narcotic), including alcohol.
(2) Regular narcotic treatment program attendance.
(3) Absence of serious behavioral problems at the narcotic treatment program.
(4) Absence of known recent criminal activity.
(5) Stability of the patient 's home environment and social relationships.
(6) Length of time in comprehensive maintenance treatment.
(7) Assurance that take-home medication can be safely stored within the patient 's home.
(8) Whether the rehabilitative benefit to the patient derived from decreasing the frequency of attendance outweighs the potential risks of drug diversion.
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Observations
Based on the review of patient records, the facility failed to document that the narcotic treatment physician considered the specified criteria for take-home criteria in making the determination that a patient was responsible in handling narcotic drugs in one of eight patient records.
The findings include:
Nineteen patient records were reviewed on March 16-18, 2010. Eight patient records were reviewed for compliance with take-home requirements. There was no documentation in patient record # 3 that the narcotic treatment physician considered the patient's regular program attendance in determining that the patient was responsible in handling narcotic drugs.
Documentation in patient record # 3 indicated the patient resumed take-home privileges on February 24, 2010. The patient had no documented counseling sessions for the months of January and February, 2010 and take-home privileges had been revoked by physician order.
The patient resumed take-home privileges on February 24, 2010 but there is no documentation that of the physician determination and order for the patient to resume take-home privileges.
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Plan of Correction
The Program Director and Clinical Supervisor will hold a training within 30 days to review the importance of completing the 8-point criteria for all patients. All clinicians will present the 8-point criteria in paper form and will be signed off by the clinical supervisor and placed in the chart, before it is submitted for approval by the Medical Director.
The clinical supervisor will review in individual supervision as needed.
The Clinical Supervisor will be responsible for signing the 8-point evaluation and to monitor compliance. The Program Director will do sporadic checks to monitor compliance.
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715.16(c)(1)(i-iv) 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:
(1) A narcotic treatment program may permit a patient to reduce attendance at the narcotic treatment program for observation to three times weekly and receive no more than a 2-day take-home supply of medication when, in the reasonable clinical judgment of the narcotic treatment physician, which is documented in the patient record:
(i) A patient demonstrates satisfactory adherence to narcotic treatment program rules for at least 3 months.
(ii) A patient demonstrates substantial progress in rehabilitation.
(iii) A patient demonstrates responsibility in handling narcotic drugs.
(iv) A patient demonstrates that rehabilitation progress would improve by decreasing the frequency of attendance for observation.
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Observations
Based on the review of patient records, the facility failed to document that a patient permitted to reduce attendance at the narcotic treatment program for observation to three times weekly and received a 2-day take-home supply of medication, demonstrated satisfactory adherence to narcotic treatment program rules for at least 3 months in one of four patient records.
The findings include:
Nineteen patient records were reviewed on March 16-18. 2010. The review revealed that four patients had been granted a 2 day take-home supply of medication. The facility did not document that patient # 5 had demonstrated satisfactory adherence to narcotic treatment program rules for at least 3 months.
Patient # 5 was admitted on July 6, 2009. The patient was in treatment less than 3 months when he was reviewed for take-home privileges. The physician's order, dated September 20, 2009, ordered the take-home privileges to commence one day following the patient's 90 days in treatment. The patient had an unauthorized absence from the facility on September 16, 2010, failing to appear for dosing as scheduled. The facility failed to document that this episode of non attendance with dosing was addressed nor was it identified in the documentation of the consideration to grant take-home privileges for patient # 5.
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Plan of Correction
The Program Director and Clinical Supervisor will hold a training within 30 days to explain the importance of not submitting take homes for the Dr.'s approval prior to their 90th day in treatment. All clinicians will present the 8-point criteria in paper form and will be signed off by the clinical supervisor then placed in the chart, before being submitted for approval by the Medical Director. This will also be addressed in individual supervision. The Clinical Supervisor will be responsible for signing the 8-point evaluation and for monitoring compliance. The Program Director will do sporadic checks to monitor compliance.
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715.17(b) LICENSURE Medication control
(b) A narcotic treatment program shall develop policies and procedures regarding verbal medication orders, including the issuing and receiving of orders, identifying circumstances when orders are appropriate and documenting orders, in accordance with applicable Federal and State statutes and regulations.
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Observations
Based on the review of patient records, the facility failed to ensure the physician
submitting a verbal order signed the verbal order within 24 hours in accordance with applicable Federal and State statues and regulations, in one of three patient records.
The findings include:
Nineteen patient records were reviewed on March 16-18, 2010. Three patient record reviewed contained documentation of a verbal order in the patient record. The facility did not document that the verbal order was put in writing and signed within 24 hours thereafter by the prescribing physician in patient record # 5.
Patient record # 5 contained documentation of a verbal order that was given by a narcotic treatment physician on September 20, 2009. The written order was approved and signed by a second narcotic treatment physician on September 21, 2009. There was no documentation in the patient's record that addressed the reason the prescribing doctor had not signed the written order.
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Plan of Correction
The Program Director will meet with the Medical Director and the medical staff within 30 days to discuss the required procedure for documentation if a physician signs a verbal order provided by another physician. The medical staff will be informed that the physician providing the verbal order must sign the written order. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on the review of patient records, the facility failed to document that patients were provided an average of 2.5 hours of psychotherapy per month during the patients first 2 years, 1 hour of which shall be individual psychotherapy in six of ten patient records.
The findings include:
Nineteen patient records were reviewed on March 16-18, 2010. Ten patient records were reviewed for compliance with an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years. The facility failed to provide documentation that the patient had received an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in patient records # 1, 2, 4, 5, 6 and 8.
Patient # 1, admitted October 7, 2009, received 1.5 hours of counseling in December 2009, 1.5 hours of counseling in January 2010 and 2.5 hours of counseling in February 2010 for an average of 1.83 hours of counseling for the past three months.
Patient # 2 admitted June 18, 2009, received 1.5 hours of counseling in December 2009, 2.0 hours of counseling in January 2010 and 2.5 hours of counseling in February 2010 for an average of 2.00 hours of counseling for the past three months.
Patient # 4, admitted November 19, 2009, received 2.5 hours of counseling in December 2009, 2.5 hours of counseling in January 2010 and 1.5 hours of counseling in February 2010 for an average of 2.17 hours of counseling for the past three months.
Patient # 5, admitted July 6, 2009, received 1.5 hours of counseling in December 2009, 1.5 hours of counseling in January 2010 and 1.5 hours of counseling in February 2010 for an average of 1.5 hours of counseling for the past three months.
Patient # 6, admitted December 19, 2009, received 1.5 hours of counseling in January 2010, 1.5 hours of counseling in February 2010 and 3.0 hours of counseling in March 2010 for an average of 2.33 hours of counseling for the past three months.
Patient # 8, admitted November 12, 2009, received 0.5 hours of counseling in December 2009, 1.5 hours of counseling in January 2010 and 1.5 hours of counseling in February 2010 for an average of 1.17 hours of counseling for the past three months.
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Plan of Correction
The Program Director and Clinical Supervisor will hold training within 30 days on the regulatory requirements for patients' psychotherapy. All patients will receive a minimum 2.5 hours of psychotherapy per month during their first two years, 1 hour will be individual psychotherapy.
The clinical supervisor will address compliance in individual supervision as needed. The Clinical Supervisor will be responsible for monitoring compliance. The Program Director will do random checks to ensure compliance.
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715.20(4) 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.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document, in writing, that it notified the transferring narcotic treatment program of the admission of the patient and the initial dose given in two of three patient records.
The findings include:
Nineteen patient records were reviewed on March 16-18, 2010. Three patient records were reviewed as transfer in patients. The facility did not document, in writing, that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program in patient records # 10 and 12.
Patient #10 transferred to the facility on January 25, 2010. The facility failed to document that the transferring facility had been notified of the patient's admission and the initial dose administered.
Patient #12 transferred to the facility on January 4, 2010. The facility failed to document that the transferring facility had been notified of the patient's admission and the initial dose administered.
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Plan of Correction
The Program Director and will hold a training within 2 weeks with the medical staff to discuss the regulatory requirement to contact the transferring facility and to notify them of the dose and the date the initial dose was given to the patient, patient is being admitted and will be receiving their initial dose.
All communication will be documented in the patient's record under a dose confirmation note effective immediately.
The program Director will be responsible to monitor for compliance.
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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
Based on the review of patient records and the policy and procedure manual, the facility failed to restrict the reasons for involuntary termination to those reasons allowed by regulation in two of two patient records.
The findings include:
Nineteen patient records were reviewed on March 16-18, 2010. Two patient records were reviewed for involuntary, or therapeutic, discharge. Two patient records contained documentation of the patient being discharged for reasons other than those listed by regulation.
Patient # 4, was involuntarily discharged on February 6, 2010. The termination letter to the patient indicated a reason for termination included a failure to comply with program rules and policies. This reason for termination exceeded the reasons identified in the standards.
Patient # 6, was involuntarily discharged on March 16, 2010. The termination letter to the patient indicated a reason for termination included a failure to comply with program rules and policies. This reason for termination exceeded the reasons identified in the standards.
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Plan of Correction
The Program Director is responsible to ensure that all forms are consistent with the Pa regulation and the facility policy. The termination letter was revised on 3/31/10 and no longer states reason for termination included a failure to comply with program rules and policies. The Program Director will be responsible to ensure the correct forms are being used. |
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 the review of patient records, the facility failed to complete all required laboratory tests as part of the admission process in four of seven patient records.
The findings include:
Nineteen patient records were reviewed on March 16-18, 2010. Seven patient records were reviewed for completed laboratory tests as part of the admission process, specifically a blood serology test.
Patient records # 8, 9, 12 and 13 failed to contain documentation that blood serological testing had been administered as part of the admission process. There was no documentation in the patients records that showed the test had been completed. The documentation in the patients records stated the reason the serological test not been performed was due to patients # 8, 9, 12 and 13 having poor veins. There was no documentation of any further attempts to secure the blood serology.
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Plan of Correction
The Program Director will meet with the medical staff within 2weeks to discuss the importance of making sure each patient has the required blood serology. When medical staff are unable to obtain blood, effective immediately they will provide the patient with a lab slip, and refer them to their local hospital for the blood serology test.
Medical staff will follow-up with the patient and document referral and follow-up.
The medical staff will monitor records for compliance. The Program Director will do sporadic checks to ensure compliance
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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
Based on the review of patient records, the facility failed to prepare a treatment plan that identified the behavioral tasks a patient was to perform to complete each short-term goal in eleven of fourteen patient records.
The findings include:
Nineteen patient records were reviewed on March 16-18, 2010. Fourteen patient records were required to have a treatment plan that identified the behavioral tasks a patient was to perform in an effort to complete each short-term goal. The facility did not document the behavioral tasks the patient was to perform in patient records # 1, 2, 3, 4, 5, 6, 8, 9, 10, 11 and 16.
In patient records # 1, 2, 3, 4, 5, 6 and 11, the treatment plan did not document support services or the type and frequency of counseling the patient was to receive.
In patient records # 8, 9, 10, and 16, the treatment plan did not document the type or the frequency of counseling the patient was to receive.
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Plan of Correction
The Program Director and Clinical Supervisor held a training on 4/1/10 to identify the behavioral tasks a patient shall perform to complete each short-term goal and the regulatory requirement to document the type or the frequency of counseling the patient is to receive. Effective immediately there will be documentation of both type and frequency of counseling the patient is to recieve.
This will be addressed in individual supervision as needed. The Clinical Supervisor will be responsible for monitoring compliance prior to approving each treatment plan.
The Program Director will do sporadic checks to monitor compliance.
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