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 1 through May 3, 2012 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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715.10(a)(1) LICENSURE Pregnant patients
(a) A narcotic treatment program may place a pregnant patient, regardless of age, who has had a documented narcotic dependency in the past and who may return to narcotic dependency, on a comprehensive maintenance regime.
(1) For these patients, evidence of current physiological dependence on narcotic drugs is not needed if a narcotic treatment physician certifies the pregnancy and, exercising reasonable clinical judgment, finds treatment to be medically justified.
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Observations
Based on the review of patient records, the narcotic treatment physician failed to document his clinical judgement and medical justification why a pregnant patient was admitted with a negative drug urinalysis in one of one record reviewed.
The findings include:
Thirty-one patient records were reviewed on May 1 through May 3, 2012. Four records reviewed were of pregnant patients. One patient record reviewed required the narcotic treatment physician to document his clinical judgement and medical justification that addressed his determination to admit a pregnant patient when drug screen urinalysis revealed that no illicit drugs were in the patient's system at the time of the specimen collection and screening. The narcotic treatment physician failed to document the justification in patient record # 5.
Patient # 5 was admitted on March 2, 2012. The narcotic treatment physician failed to document the patient's current opiate addiction in the record.
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Plan of Correction
The medical director or physician will document in the electronic record his clinical judgment and medical justification why a pregnant patient will be admitted with a negative drug urinalysis. This will be done via a case consultations by the MD with at minimum program director, clinical supervisor and charge nurse in attendance. The case consultation will be completed by the MD and will show his medical justification. This has been completed as of this date 5/23/12. Charge Nurse will review via clinical and medical chart audits for compliance on a quarterly basis. |
715.16(a)(1) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(1) A narcotic treatment program may give take-home medications only to a patient who the narcotic treatment physician has determined is responsible and able to handle narcotic drugs outside the narcotic treatment program.
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Observations
Based on the review of patient records, the facility failed to ensure the narcotic treatment physician was making the decision for granting take home medication in four of four patient records.
The findings include:
Thirty-one records were reviewed on May 1 through May 3, 2012. Patient record documentation revealed that the physician's designation of take-home medications for patients was based on the decisions made by clinical staff. The patient records included documentation by the physician indicating that the clinical staff approved the take-home medication in patient records # 9, 26, 27, and 31.
This finding was discussed with the facility director on May 2, 2012.
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Plan of Correction
The Medical Director or physician will change his language in the takehome order to state that the narcotic treatment physician has determined the patient is responsible and able to handle narcotic drugs outside the treatment program. This will be documented by the Physician in the medical order which will include the rational. Program Director will review all takehome orders on a quarterly basis to ensure compliance. This will take effect on 5/25/12.
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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 narcotic treatment physician failed to exercise reasonable clinical judgment when granting take home medications to one of ten records reviewed.
The findings include:
Thirty-one records were reviewed on May 1 through May 3, 2012. Ten patient records were reviewed for the narcotic treatment physician's documentation that showed he considered the patient's requirement to have regular treatment program attendance when granting take-home privileges. The narcotic treatment physician granted patient # 18 take-home privileges on April 20, 2012. This patient failed to obtain the required psychotherapy hours for February 2012, March 2012 and April 2012. This should have been considered when granting the patient take-home medication.
Patient # 18 was admitted on January 9, 2012. During the first two years of treatment, patients are required to average 2.5 hours of psychotherapy per month, one hour must be individual psychotherapy. This patient was granted take home privileges on 4/20/2012. She only averaged 2 hours of psychotherapy for the months of February, March and April. She also failed to obtain the one hour of required individual psychotherapy in March and April. The patient only had .50 hours of individual psychotherapy during these two months.
This finding was discussed with the facility director and was not disputed.
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Plan of Correction
The Program Director will hold a training on 5/29/12 with the Medical Director and physician to review regulatory requirements for documenting the physicians rationale for granting take home medications. The training will focus on the 8 point evaluation for takehomes which includes compliance with counseling attendance. The clinical Supervisor and lead counselor will conduct monthly takehome review audits on all patients with takehomes to ensure continued compliance with the 8 point criteria. The Program Director will check take home orders to ensure the rationale is documented. This will take effect on 6/1/12. |
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 facility failed to 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 two of three patient records reviewed.
The findings include:
Thirty-one patient records were reviewed May 1 through May 3, 2012. Three patient records were reviewed for documentation of notification to the referring facility of the admission and dosing of the referred patient.
Patient records # 20 and 28 were referred by another narcotic treatment program. The records failed to contain documentation of the transferring narcotic treatment program being notified of the admission and initial dosing of the patients.
This finding was reviewed with the clinical supervisor and was not disputed.
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Plan of Correction
The Program Director will provide a training on the transfer policy and regulations which require documentation in writing that we notified the transferring narcotic treatment program of the admission date and initial dose. The dispensing staff will complete this task once their initial dose is provided to ensure compliance. The program Director will complete monthly chart reviews of all patients that transfer in and out of Discovery House. This will take effect on 6/1/12
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715.21 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.
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Observations
Based on the review of patient records, the facility failed to ensure that each patient was informed of the reason for termination prior to administratively being terminated from the program in two of three patient records.
The findings include:
Thirty-one patient records were reviewed on May 1 through May 3, 2012. Three patients required notification of involuntary termination notifications prior to discharge. The facility failed to document notification in patient records # 1 and 3.
Patient # 1 was admitted on December 19, 2006 and was administratively discharged for non-compliance of treatment. The patient started an administrative taper on November 23, 2011. The record failed to contain a letter notifying the patient of their involuntary termination and their right to appeal the decision of termination.
Patient # 3 was admitted on March 9, 2009. The patient received an administrative discharge. The record contained an order that the administrative taper was to begin on January 6, 2012. The patient did not receive the notification of termination until January 9, 2012 stating the taper would begin on January 7, 2012. The notification did not allow the patient to appeal the termination prior to the administrative detoxification taper was initiated.
This finding was confirmed by the clinical supervisor on May 2, 2012.
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Plan of Correction
A training on involuntary terminations will be provide by the program director to all staff which will include documentation of the required notification of involuntary termination and reasoning why. The training will also focus on Documenting non compliance with treatment in the electronic record. Program Director will review all potential involuntary terminations before being implemented to ensure compliance. This will take effect on 6/1/12. |
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 review of patient records, the facility failed to ensure all efforts had been initiated to retain the patient prior to the involuntary termination in one of three records.
The findings include:
Thirty-one patient records were reviewed on May 1 through May 3, 2012. Three patients were terminated involuntarily. The facility failed to ensure that all efforts had been initiated to retain patient # 8.
Patient # 8 entered treatment on February 25, 2011. The patient was administratively discharged on January 5, 2012 for noncompliance of the benzodiazepine policy and failure to comply with the treatment plan. The narcotic treatment physician's order and clinical documentation referenced listed one of the reasons for termination as failure to comply with financial obligations. The record included a case consultation documented on November 25, 2011. This consultation also indicated that the patient was being tapered due to benzodiazapine use and an unpaid balance. The documentation in the record appeared as though the patient was discharged for financial non-compliance.
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Plan of Correction
A training on involuntary terminations will be provided by the program director to all staff which will include education on permissible reasons for an administrative withdrawal and documentation of the required notification of involuntary termination. The training will also focus on Documenting non compliance with treatment in the electronic record. Program Director will review all potential involuntary terminations before being implemented to ensure compliance. This will take effect on 6/18/12
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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 review of the patient records, the facility failed to document an annual physical with a re-evaluation by the physician in nine of nine patient records reviewed.
The findings include:
Thirty-one patient records were reviewed on May 1 through May 3, 2012. Nine patient records were reviewed for annual physical exams that included a re-evaluation by the physician. The physician failed to document a re-evaluation that included why the patient should continue in methadone maintenance treatment in patient records # 1, 12, 13, 22, 24, 25, 26, 29, and 30.
Patient # 1 was admitted on December 19, 2006 and discharged on January 12, 2012. The physician assistant completed an annual physical on December 12, 2011. The annual physical examination reported the patient being on a 30 day taper. The physician's medical note on December 19, 2011 stated the patient was to continue on the present dose of methadone. The medical note did not reference the administrative taper that was taking place against medical advice.
Patient records # 12, 13, 22, 24, 25, 26, 29, and 30 contained an annual physical examination completed by the physician assistant. The physician documented a medical note in these records that stated, "continue present dose of methadone." The documentation was not a re-evaluation that provided justification that the patient should continue in methadone maintenance treatment.
This is a repeat citation from the May 3 through May 5, 2011 methadone monitoring inspection.
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Plan of Correction
The Program Director will provide a training to the Medical Director and Physician on documentation as it relates to the annual physical evaluation. This training will take place on 5/23/12. The medical director and physician will document rational for continued treatment or medically supervised withdrawal on all annual evaluations. The Program Director will monitor this via quarterly reviews of all annual physical evaluations. This will take effect on 6/1/12 |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on the review of patient records, the facility failed to ensure that verbal medication orders are put in writing and signed within 24 hours thereafter by the prescribing physician, as required by regulation and facility policy and procedure, in two of three patient records.
Additionally, the facility has a computerized record system that allows for someone other than the narcotic treatment physician to enter components of an order.
The findings include:
Thirty-one patient records were reviewed on May 1 through May 3, 2012. Three patient records contained telephone verbal orders by one physician, but they were signed by another physician. Verbal orders must be signed by the physician who initially issued the verbal order.
Patient # 10 had a telephone verbal order initiated by the medical director on September 9, 2011. The order was signed off on September 12, 2011 by a different narcotic treatment physician. This order was not signed off within the required 24 hours and it was not signed by the physician who initiated the order.
Patient # 25 had a telephone verbal order from the medical director documented on December 29, 2011. The order was signed off within 24 hours by a different narcotic treatment physician. It was not the physician who initiated the order.
Patient # 26 had a telephone verbal order from the medical director on October 28, 2011. The order was signed off on October 31, 2011 by a different narcotic treatment physician. This order was not signed off within the required 24 hours and it was not signed by the physician who initially issued the order.
Patient records # 5, 17 and 18 contained documentation of verbal orders that were entered into the facility's electronic record system by the physician's assistant. These orders were signed by a narcotic treatment physician. Only a physician may issue a verbal order.
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Plan of Correction
A training will be provided to all staff on Medication Control on 6/6/12 which will include Verbal Orders. The training will include that only the Medical Director and Physician can enter components of an order, and all verbal orders need to be signed via the electronic signature within 24 hours. Program Director will conduct quarterly reviews of all orders posted to ensure compliance. This will take effect 6/11/12 |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to provide written documentation of the proposed type of support service, in the individual treatment and rehabilitation plans, in six of nine records.
The findings include:
Thirty-one patient records were reviewed on May 1 through May 3, 2012. Nine patient records were reviewed for an individual treatment and rehabilitation plans that included proposed type of support services. The facility did not document proposed type of support services in client records # 5, 6, 7, 10, 15, and 19.
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Plan of Correction
A training will be provided by the clinical supervisor and lead counselor to all clinical staff on identifying proposed types of support services. The training will include where to document these support services in the treatment plan. The training will take place on 5/30/12. Clinical Superviser to ensure support services are documented in the treatment plan before approval of all treatment plans. The Program Director will complete quarterly chart reviews to ensure overall compliance. This will take effect on 6/11/12
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