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 February 19-21, 2013 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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715.6(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, the facility failed to provide at least one hour of physician time a week, on site, for every ten patients for multiple weeks during the time period reviewed. .
The findings include:
The administrative documentation reviewed included physician time sheets and and census reports for the months of October 2012, November 2012, December 2012, January 2013 and the beginning of February 2013, were reviewed February 19 and 20, 2013. There were insufficient onsite physician hours during October, November, December, January and February. .
During the week of October 28, 2012, the census was 376 and 22.23 physician hours were documented as provided to the facility's patients during this time period.
During the week of November 4, 2012, the census was 378 and 36.47 physician hours were documented as provided to the facility's patients during this time period.
During the week of November 11, 2012, the census was 378 and 29.07 physician hours were documented as provided to the facility's patients during this time period.
During the week of November 18, 2012, the census was 376 and 21.57 physician hours were documented as provided to the facility's patients during this time period.
During the week of November 25, 2012, the census was 376 and 35.97 physician hours were documented as provided to the facility's patients during this time period.
During the week of December 9, 2012, the census was 376 and 35.57 physician hours were documented as provided to the facility's patients during this time period.
During the week of December 16, 2012, the census was 381 and 35.92 physician hours were documented as provided to the facility's patients during this time period.
During the week of December 24, 2012, the census was 385 and 21.03 physician hours were documented as provided to the facility's patients during this time period.
During the week of January 20, 2013, the census was 380 and 30.13 physician hours were documented as provided to the facility's patients during this time period.
During the week of January 27, 2013, the census was 383 and 32.35 physician hours were documented as provided to the facility's patients during this time period.
During the week of February 3, 2013, the census was 374 and 28.50 physician hours were documented as provided to the facility's patients during this time period.
During the week of February 10, 2013, the census was 374 and 28.50 physician hours were documented as provided to the facility's patients during this time period.
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Plan of Correction
The Director permanently revised the onsite physician schedule to endure sufficient onsite physician hours beginning 3/25/2013. The schedule will include one hour of physician time a week, on site, for every ten patients.
The Director is responsible for monitoring the physician schedule and onsite physician hours to ensure compliance. |
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, the facility failed to ensure the proper facilitation of the consent to release information in the transferring of patient's records in five of five patient records reviewed.
The findings include:
Twenty nine patient records were reviewed February 19-21, 2013. Five patient records were reviewed for documentation of the releases of information signed by the patient when they were transferred.
Patient # 9 was transferred to another narcotic treatment facility January 7, 2013. The transfer required specific information to be sent to the receiving facility with patient's written consent. While a consent to release information was signed by the patient, the specific information listed did not cover what information was to be sent.
Patient # 10 was transferred to another narcotic treatment facility October 3, 2012. The transfer required specific information to be sent to the receiving facility with patient's written consent. While a consent to release information was signed by the patient, the specific information listed did not cover what information was to be sent.
Patient # 11 was transferred to another narcotic treatment facility January 31, 2013. The transfer required specific information to be sent to the receiving facility with patient's written consent. While a consent to release information was signed by the patient, the specific information listed did not cover what information was to be sent.
Patient # 12 was transferred to another narcotic treatment facility January 29, 2013. The transfer required specific information to be sent to the receiving facility with patient's written consent. While a consent to release information was signed by the patient, the specific information listed did not cover what information was to be sent.
Patient # 27 was transferred in to the facility on October 5, 2012. The facility documented in a note, dated October 8, 2012, that the referring facility was notified of the admission and dosing of the patient. However, there was no consent to release information signed by the patient prior to the notice of the transfer.
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Plan of Correction
The Clinical Supervisor provided an in-service on 2/26/2013 to reinforce the proper facilitation of the consent to release information in the transferring of patient's records. The Clinical Supervisor stressed the requirement for the Release of Information to match the information sent and the need for a signed Release of Information before any information is sent.
The Clinical supervisor or designee will audit all transfer out patients records for compliance.
The Director is responsible for ensuring the compliance and audit process. |
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 the review of patient records, the facility failed to complete an initial urine drug screen prior to the initial dose for two of seven patient records reviewed.
The findings include:
Twenty nine patient records were reviewed February 19-21, 2013. Seven patient records were reviewed for the initial urine drug screen results.
Patient # 2 was admitted to the facility on November 26, 2012. The patient had recently discharged from the same facility on October 10, 2012 due to medical issues. The first urine drug screen completed on the patient was dated December 21, 2012, almost one month after admission.
Patient # 28 was admitted November 30, 2012. An initial urine drug screen was collected November 28, 2012. The results were returned to the facility from the laboratory on December 1, 2012. The patient received the initial narcotic dose of 10 milligrams on November 30, 2012. The physician acknowledged the urine drug screen results had not been received and/ or reviewed prior to the first dose.
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Plan of Correction
The Admission Team will ensure that an initial urine drug screen is completed prior to the initial dose of methadone.
The Senior Counselor or designee will audit each record prior to the initial dose of methadone to ensure a urine drug screen result is in the electronic medical record or chart beginning 3/25/2013.
The Director provided a Medical Team in-service to ensure the urine drug screen results are in the chart prior to the initial dose of methadone.
The Director is responsible for ensure each admission has a urine drug screen result in the chart prior to the initial dose of methadone. |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on the review of patient records, the facility failed to ensure the dose reviews were completed by the narcotic treatment physician in nine of eleven patient records.
The findings include:
Twenty nine patient records were reviewed February 19-21, 2013. Eleven patient records were reviewed for the required semi-annual dose review by the narcotic treatment physician. Nine patient records contained documentation of the Certified Physician Assistant (PA-c)completing the semi-annual dose review.
Patient # 5 was admitted February 27, 2012 and had a documented dose review by the
PA-c.
Patient # 8 was admitted February 22, 2011 and had a documented dose review by the
PA-c dated December 4, 2012 and signed by the narcotic treatment physician December 5, 2012.
Patient # 19 was admitted January 22, 2001. There was a documented dose review by the
PA-c dated January 22, 2013 and signed by the narcotic treatment physician January 23, 2013
Patient # 20 was admitted June 4, 2012. There was a documented dose review by the
PA-c dated December 6, 2012.
Patient # 22 was admitted October 29, 2008. There was a documented dose review by the
PA-c dated December 6, 2012.
Patient # 23 was admitted December 20, 1996. There was a documented dose review by the PA-c dated December 28, 2012.
Patient # 24 was admitted March 2, 2009. There was a documented dose review by the
PA-c dated September 5, 2012.
Patient # 25 was admitted May 16, 2011. There was a documented dose review by the
PA-c dated November 8, 2012.
Patient # 26 was admitted March 23, 2011. There was a documented dose review by the
PA-c dated September 20, 2012.
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Plan of Correction
The Director provided an in-service with the Medical Director and Physician Assistant to ensure the dose reviews are completed by the narcotic treatment physician beginning 3/25/2013.
The Director will audit random charts to ensure cmpliance beginning 3/25/2013 |
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 signed his verbal orders within 24 hours of submission of the verbal order in two of three patient records reviewed.
The findings include:
Twenty nine patient records were reviewed February 19-21, 2013. Three records contained documentation of a physician's verbal orders. While the physician did sign these verbal orders, the signature was not documented until two days after the verbal order was issued in two of the patient records.
Patient # 16 was admitted February 13, 2013. A verbal order was issued by the narcotic treatment physician on February 14, 2013, but was not signed by the issuing physician until February 16, 2013, more than 24 hours after the order was issued.
Patient # 17 was admitted February 4, 2013. A verbal order was issued by the narcotic treatment physician on February 7, 2013, but was not signed by the issuing physician until February 9, 2013, more than 24 hours after the order was issued.
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Plan of Correction
The Director provided an in-service with the Medical Director to review the State of PA requirement for a physician to sign his verbal orders within 24 hours of submission of the verbal order.
The physician's will sign all his verbal orders within 24-hours of submission of the verbal order beginning on 3/25/2013.
The Director will audit random charts to ensure compliance wit hthe physician signing his verbal orders within 24 hours of submission of a verbal order. |
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 the review of patient records, the facility failed to complete the annual physical of the patient with a re-evaluation by the physician in four of four patient records reviewed.
The findings include:
Twenty nine patient records were reviewed February 19-21, 2013. Four patient records were reviewed for the patient's annual physical. The four records reviewed demonstrated the annual physical was completed by the Certified Physician Assistant (PA-c).
Patient # 8 was admitted November 22, 2011. The PA-c completed the physical December 4, 2012. While the physician signed the documentation of the physical on December 5, 2012, the physician did not include the annual re-evaluation as required.
Patient # 19 was admitted January 22, 2001. The PA-c completed the physical January 22, 2013. The physician did not provide documentation of the annual re-evaluation as required.
Patient # 22 was admitted October 29, 2008. The PA-c completed the physical October 17, 2012. The physician did not provide documentation of the annual re-evaluation as required.
Patient # 20 was admitted December 20, 1996. The PA-c completed the physical December 28, 2012. The physician did not provide documentation of the annual re-evaluation as required.
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Plan of Correction
The Director provided an in-service with the Medical Director to review the State of PA requirement for the annual physical of the patient with a re-evaluation by the physician.
The Medical Director will ensure the physician complete the annual physical of the patient with a re-evaluation by the physician by 3/25/2013.
The Director will randomly audit chart to ensure compliance with the State of PA requirement to ensure compliance. |
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 facility failed to ensure the comprehensive treatment plans were completed within the time frame according to policy in two of three patient records reviewed.
The findings include:
Twenty nine patient records were reviewed February 19-21, 2013. Three patient records were reviewed for completion of the comprehensive treatment plans within the 30 days of admission as stated in the facility's policy and procedure manual.
Patient # 27 was admitted October 5, 2012. The psychosocial evaluation was completed October 16, 2012, but the comprehensive treatment plan was not completed until November 21, 2012. This was more than 30 days after admission.
Patient # 29 was admitted December 10, 2012. The psychosocial evaluation was completed December 17, 2012, but the comprehensive treatment plan was not completed until January 17, 2013. This was more than 30 days after admission.
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Plan of Correction
The Clinical Supervisor re-enforced during clinical supervision the requirement for the comprehensive tratment plan to be completed within the time fram according to Discovery House Policy. The Clinical Team will ensure the initial treatment plan is completed within the timeframe of the Discovery House Policy by 3/25/2013.
The Clinical Supervisor or designee will audit random charts to ensure Policy compliance.
The Director is responsible for ensuring compliance with the Policy and the audit process. |