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 January 14-16, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House, 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.
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Plan of Correction
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715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on the review of patient records, the facility failed to verify the identity of the patient prior to the administration of an agent in three of seven patient records reviewed.
The findings include:
Nineteen patient records were reviewed January 14-16, 2014. Seven patient records were specifically reviewed for patient identity information. Patient records # 11, 18 and 19 did not contain any documentation to verify the patient's identity.
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Plan of Correction
The Clinical Supervisor or designee will conduct an in-house training with the Admission Staff on the requirement to verify the identity of each patient prior to the administration of an agent. The training will include but is not limited to the where to store the image of the patient in the electronic medical record.
The Clinical Supervisor or designee will audit new admissions to ensure compliance with the requirements of State of PA M055.
The Director is responsible for ensuring the in-house training is completed by March 11, 2014 and the correction is made by March 24, 2014. |
715.23(d) 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.
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Observations
Based on the review of patient records, the narcotic treatment program failed to document realistic short and long-term treatment goals in six of eleven patient records.
The findings include:
Nineteen patient records were reviewed January 14-16, 2014. Treatment plans with realistic short and long-term treatment goals were required in seventeen patient records. Eleven patient records were reviewed specifically for treatment plans. Patient records # 1, 10, 11, 13, 18 and 19 all contained treatment plan goals that did not reflect the nature of the problem statement. The problem statement on each was related to their respective drug dependencies. However, the short term goals/objectives for the problem area required that they pay their fee or maintain their insurance coverage. None of the six patient records reflected that payment was an issue at the time of the development of the treatment plan goals.
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Plan of Correction
The Clinical Supervisor or designee will conduct an in-house training on how to develop treatment plan with realistic short and long term treatment goals. The training will include but not limited to the appropriate use of each dimension and the inclusion of such things as payment of fees or maintaining their insurance coverage for use when a problem or potential problem is identified.
The Clinical Supervisor or designee will audit treatment plans to ensure compliance with the State of PA M269 guidelines.
The Director is responsible for ensuring the in-house training occurs by March 11, 2014 and the corrective action is active by March 24, 2014. |
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
Based on a review of patient records, the facility failed to comply with the conditions of the exceptions granted by the division regarding 13 day take home privileges in two of two patient records reviewed.
The findings include:
Nineteen patient records were reviewed January 14-16, 2014. Two patient records required compliance with the conditions of exceptions granted by the division regarding 13 day take home privileges. The exceptions granted required quarterly call backs for patient's # 6 and # 7. The call backs are to be an unscheduled return to the facility within 24 hours of the facility calling the patient back to procure an inventory of the patient's remaining take home supply and a urine drug screen.
Patient # 6 was reviewed for quarterly call backs between January 23, 2013 and January 15, 2014. There were call backs on August 15, 2013, October 2, 2013 and January 15, 2014. On April 10, 2013, there was a note from the assigned counselor stating "too soon" with no further explanation.
Patient # 7's record did not contain documentation of an exception granted by the Division at the time of the inspection.
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Plan of Correction
The Clinical Supervisor or designee will conduct an in-house training on the State of PA requirements for the conditions of the exceptions granted by the division regarding 13-day take home bottle privileges. The training will include but is not limited to educating staff on the requirement for quarterly call backs and the need to have the documentation of the exception granted by the Division at the time of the inspection.
The Clinical Supervisor or designee will audit the charts for the 13-day take home bottle patients to ensure the call backs are done quarterly and the documentation is in the chart at the time of the inspection.
The Director is responsible for ensuring the in-house training is completed by March 11, 2014 and the process to correct the issue by March 24, 2014. |