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 from June 8, 2011 through June 10, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center for Behavioral Health, PA 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 and discussion with administrative staff, the facility failed to provide at least one hour of physician time per week, on site, for every ten patients for seven of eighteen weeks reviewed.
The findings include:
The physician and the certified registered nurse practitioners time sheets and the census reports for January 29, 2011 to June 3, 2011 were reviewed on June 8, 2011. There were insufficient onsite physician hours for the weeks of January 29, March 5, March 26, April 2, April 30, May 21 and May 28, 2011.
During the week of January 29, 2011, the census was 499. The total physician time documented was 47.37 hours.
During the week of March 5, 2011, the census was 493. The total physician time documented was 44.83 hours.
During the week of March 26, 2011, the census was 496. The total physician time documented was 40.88 hours.
During the week of April 2, 2011, the census was 491. The total physician time documented was 44.02 hours.
During the week of April 30, 2011, the census was 492. The total physician time documented was 41.23 hours.
During the week of May 21, 2011, the census was 486. The total physician time documented was 44.57 hours.
During the week of May 28, 2011, the census was 486. The total physician time documented was 31.00 hours.
The facility director reviewed the time sheets and census reports on June 8, 2011. The facility director was interviewed on June 8, 2011 @ 11:06 A.M. and confirmed the total physician hours were insufficient for the weeks listed above.
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Plan of Correction
A PRN CRNP has been hired and will be utilized the weeks when CRNP hours are shortened due to vacation or illness. This will be arranged in advance so that no future weeks are insufficient for physician hours. Medical Director is charged to ensure physician hours meet regulation requirements. Program Director will monitor. |
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 the review of patient records and an interview with the facility director, the facility failed to maintain the confidentiality of all patient records in accordance with 42 CFR Part 2, Subpart B, subsection 2.22 (relating to notice to patients of Federal confidentiality requirements) and 28 Pa. Code 709.28 (relating to confidentiality) in two of fourteen patient records.
The findings include:
Twenty nine patient records were reviewed on June 8-10, 2011. Fourteen patient records were reviewed for compliance in the maintaining of the confidentiality of all patient records in accordance with 42 CFR Part 2, Subpart B, subsection 2.22 (relating to notice to patients of Federal confidentiality requirements) and 28 Pa. Code 709.28 (relating to confidentiality). The facility did not maintain the confidentiality of patient records # 22 and 25.
Patient # 22 was admitted on August 26, 2010. An individual progress note dated December 16, 2010 documented that the patient's father had been present during the session. There was no consent to release information form documented for the father.
Patient # 25 was admitted on February 16, 2017. A grievance filed by the patient in March, 2011 stated that her confidentiality had been violated as a result of information released to the Medical Assistance Transportation Office. Upon review of the patient's record, the documentation showed that information released to the Medical Assistance Transportation Office exceeded the information listed on the consent to release information form signed by the patient.
The facility director was interviewed on June 8, 2011 @ 1:57 P.M. and confirmed that patient record # 22 had no documentation that a release had been obtained for the father and that the information released to the Medical Assistance Transportation Office in patient record # 25 exceeded the information listed on the consent to release information form signed by the patient.
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Plan of Correction
All Associates will be required to review Discovery House's Confidentiality policy (which reviews 42 CFR Part 2, HIPPA, Federal and State regulations) and pass an electronic quiz given after. Associates without a passing score will be directed to immediate Supervisor to schedule and complete a formal training.
To ensure violations of confidentiality do not occur again, Clinical Supervisors are charged to regularly review consents to release along with the disclosure made on the consents.
Program Director will monitor to ensure all Associates comply with confidentiality laws and regulations. |
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 and an interview with the facility director, the facility failed to document that the narcotic treatment program had given take-home medications only to a patient who the narcotic treatment physician had determined is responsible and able to handle narcotic drugs outside the narcotic treatment program in one of ten patient records.
The findings include:
Ten patient records were reviewed for take home medication documentation on June 8-10, 2011. Per regulation, 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.
Patient # 9 was admitted on February 1, 2010 and was immediately given take home medication. The patient continues to have take home medication. There was no documentation at the time of admission, or currently, that the narcotic treatment physician had determined the patient was responsible and able to handle narcotic drugs outside the narcotic treatment program.
The facility director was interviewed on June 10, 2011 @ 1:05 P.M.. The facility director reviewed patient record # 9 and confirmed there was no documentation that the physician had determined the patient was responsible and able to handle narcotic drugs outside the narcotic treatment program.
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Plan of Correction
Documentation was obtained from patient's previous treatment provider since inspection. With documents obtained, Medical Director was able to determine patient #9 is responsible to handle take home medication. Patient's chart and order has been updated by Medical Director.
Effective immediately, Medical Director will not place an order for take home medication unless documentation is in hand to identify that transfer patient is responsible to handle narcotic drugs outside of narcotic treatment program.
Program Director will perform audits on each patient that transfers into treatment to ensure compliance to take home medication regulation is followed. |
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 ensure the physician documented in the patient record the rationale for granting take home medication in one of ten patient records.
The findings include:
Ten patient records were reviewed for take home medication documentation on June 8-10, 2011. Per regulation, the narcotic treatment physician shall document in the patient record the rationale for permitting take home medication. There was no physician documentation of the rationale in the granting of take home medication in patient record # 9.
Patient # 9 was admitted on February 1, 2010 and was immediately given take home medication. The patient continues to have take home medication. There was no documentation at the time of admission, or currently, of the physician's rationale for granting the take home medication.
The facility director was interviewed on June 10, 2011 @ 1:05 P.M.. The facility director reviewed patient record # 9 and confirmed there was no documentation of the physician rationale for granting take home medication.
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Plan of Correction
To correct this deficiency, Medical Director documented the rational for the take home status ordered, utilizing the 8 point form.
Effective immediately, Medical Director will clearly document the rational for ordering take home medication in the 8 point form.
Program Director will monitor for compliance. |
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 a review of patient records and an interview with the facility director, the facility failed to consider the criteria for take-home privileges in one of ten patient records.
The findings include:
Ten patient records were reviewed on June 8-10, 2011 for compliance with the regulations regarding take-home medications.
Patient # 9 was admitted into treatment on February 1, 2010. Patient # 9 transferred into treatment from another narcotic treatment program and was immediately granted take-home privileges. The patient currently receives take home medication for thirteen days. There was no documentation that the criteria had been considered for take-home privileges in patient record # 9.
The facility director was interviewed on June 10, 2011 @ 1:05 P.M. She reviewed patient record # 9 and confirmed that there was no documentation that the criteria had been considered prior to granting take-home privileges.
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Plan of Correction
To correct this deficiency, Medical Director completed documentation to show that criteria had been considered for the current take home status ordered, utilizing the 8 point form.
Effective immediately, Medical Director will clearly document that the criteria for take home status was considered by utilizing the 8 point form before an order is placed.
Program Director will monitor for 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 and an interview with the facility director, the facility failed to document in writing that it notified the transferring narcotic treatment program of the date of the initial dose given to the patient by the receiving narcotic treatment program in two of two patient records.
The findings include:
Two patients were transferred into treatment from a narcotic treatment program. The patient records were reviewed on June 8-10, 2011. Per regulation, 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. The facility failed to document in writing that it notified the transferring narcotic treatment program of the date of the initial dose given to the patient in records # 5 and 6.
Patient # 5 was transferred from a narcotic treatment program and admitted into treatment on November 2, 2010. There was no documentation that the facility notified the transferring narcotic treatment program of the initial dose given to the patient.
Patient # 6 was transferred from a narcotic treatment program and admitted into treatment on January 28, 2011. There was no documentation that the facility notified the transferring narcotic treatment program of the date of the initial dose given to the patient.
The facility director was interviewed on June 9, 2011 @ 2:10 P.M. and confirmed there was no documentation that the facility had notified the transferring narcotic treatment program of the date of the initial dose given to the patient in patient records # 5 and 6.
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Plan of Correction
A request has been placed to update Transfer Acknowledgement Form to include the date of the initial dose given to patient.
Effective immediately, Associates will hand write the date of the initial dose given to the patient before sending notification to the transferring narcotic treatment program.
Intake coordinator is charged to ensure this regulation is followed by performing chart audits on each patient who transfers into treatment.
Program Director will monitor for compliance to regulation. |
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 and an interview with the facility director, the facility failed to request an exception to provide take home bottles beyond the 6 take home bottles allowed by regulation in one of two patient records.
The findings include:
Two patient records reviewed on June 8-10, 2011 required an exception for the granting of take home bottles beyond the 6 day take home bottles allowed by regulation. There was no documentation of the required exception in patient record # 9.
Patient # 9 was admitted on February 10, 2010. The patient currently receives take homes which are beyond the 6 day take home bottles allowed by regulations. There was no documentation that the facility had requested an exception for this patient.
An interview with the facility director on June 10, 2011 @ 1:05 P.M. confirmed that there was no documentation that an exception to the take homes had been requested in patient record # 9.
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Plan of Correction
To ensure compliance with Department of Health regulation regarding exceptions, Medical Director placed a new order to remove patient from 13 day take home medication.
Effective immediately, Medical Director will not place an order for 13 day take home medication without an approved exception from the Department of Health.
With assistance from Clinical Supervisors, Program Director will audit patients who have exceptions to take home medication to ensure Discovery House remains in compliance with regulation. |