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 August 12-14, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Health Masters, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on September 25, 2008.
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Plan of Correction
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715.10(d) LICENSURE Pregnant patients
(d) Within 3 months after termination of pregnancy, the narcotic treatment physician shall enter an evaluation of the patient 's treatment status into her record and state whether she should remain in comprehensive maintenance treatment or receive detoxification treatment.
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Observations
Based on the review of 16 patient records on August 13 and 14, 2008, four patients were reviewed for pregnancy and recent delivery. One was required to have an evaluation of their treatment status by the physician. The facility failed to ensure the evaluation by the physician was completed.
Findings:
Patient record #14-who was admitted to the facility in December 2007 because she was pregnant, delivered while in treatment sometime in March 2008. The Certified Registered Nurse Practitioner wrote a follow up note, but the physician never entered the evaluation as required.
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Plan of Correction
The requirement regarding the physician evaluation of a
pregnant patient within 3 months post partum will be
fulfilled by the utilization of a Pregnancy/Well Being Form
that is to be maintained by the nursing staff. Upon
delivery, the completed form will be forwarded to the
nurse practitioner, who will be responsible for scheduling
a face to face evaluation and assessment with the physician.
Physician will be responsible for documenting the
appropriateness for continued treatment for patient in the
patient record. Effective by October 1, 2008.
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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 the review of 16 patient records on August 12, 13 and 14, 2008, 16 were required to have a completed urinalysis at least monthly. The facility failed to ensure monthly random urinalysis for two patients, who were transfers and had their last urinalysis completed in May 2008 prior to their transfer the Health Masters, Inc.
Findings:
Patient record #12 was missing a drug-screening urinalysis for June 2008.
Patient record #13 was missing a drug-screening urinalysis for June 2008.
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Plan of Correction
Health Masters has amended its policy regarding urine
testing to state that all patients will submit a urine
sample on the day of admission prior to receiving
medication. Nursing staff will be responsible for
ensuring that a urine sample is collected prior to
a patient receiving initial dose. This amended policy will
ensure that all new patients, including transfers into the
program, will submit a urine sample every month. Effective
by October 1, 2008.
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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 16 patient records on August 12, 13 and 14, 2008, three were required to have physician determination of the provision of take home medications. The facility failed to include this documentation in two of three patient records where required.
Findings:
Current take home request form is set up so that the physician "agrees" with whomever is making the determination.
Record # 13 was missing the physician's determination of the take home
Record # 14 was missing the physician's determination or order for the take home bottles granted.
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Plan of Correction
Health Masters has amended the Take Home Privilege
Form used for documentation of issuance and rescinding
of take home medication to include physician determination
of patient status rather than physician comments. Physician
will be responsible for completing form and documenting
the resulting take home privileges based on discussion and
final determination. Facility Director will be responsible for familiarizing staff with form through an in-house training on the appropriate use of the form and the adherence to policy and standards. Facility Director will also be responsible for the proper and ongoing use of form during interdepartmental meetings and clinical review of privilege status of patients. Effective November 1, 2008.
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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 16 patient records on August 12, 13 and 14, 2008, three were required to have the physician document the rationale for permitting take home medications. The facility failed to ensure the physician documented the rationale for permitting take home bottles in two of three patient records where required.
Findings:
Patient record #13 was missing the physician's rationale for permitting the take home medication.
Patient record #14 was missing the physician's rationale for permitting the take home medication.
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Plan of Correction
Health Masters has amended the Take Home Privilege Form used for documentation of issuance and rescinding of take home medication to include physician determination of patient status rather than physician comments. Physician will be responsible for completing form and documenting the resulting take home privileges based on discussion and final determination. Facility Director will be responsible for familiarizing staff with form through an in-house training on the appropriate use of the form and the adherence to policy and standards. Facility Director will also be responsible for the proper and ongoing use of form during interdepartmental meetings and clinical review of privilege status of patients. Effective November 1, 2008. |
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 16 patient records, administrative documents and staff interviews on August 12, 13 and 14, 2008, five records were required to have documentation demonstrating all efforts were made to retain the patient in treatment prior to initiating involuntary termination, but documentation was missing in one of five records where required.
Findings:
Record #8 was missing documentation demonstrating that all efforts were made to try to retain the patient prior to involuntarily termination. The last progress note was written on 5/28/08 and addressed the progress the patient was making. There was no documentation of any effort to encourage th patient to sign the requested consent to release information form required by the facility physician for coordination of treatment services, but rather the patient was put on a 7-day detoxification schedule immediately after refusing to sign the consent.
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Plan of Correction
Health Masters will exert all efforts to try to retain the patient prior to involuntarily termination. Health Masters will continue to utilize an Involuntary Termination Form that requires signatures from patient, counselor, supervisor, and physician, as well as the reason for termination, stated on the form. The responsibility of terminating a patient's treatment will rest with the counselor, supervisor, and physician, who will comprise a team approach in documenting the reasons that necessitate a patient termination. Physician will be responsible for making final determination in termination of patient's treatment, and will document in patient record.
Facility Director will educate staff regarding process and compliance with policy and standards through an in-house training. Facility Director will also be responsible for reviewing process of patient termination and determining ongoing compliance with standard. Training and compliance effective November 1, 2008. |
715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
Based on the review of administrative records and staff interviews on August 12 and 13, 2008, the facility failed to include policies and procedures that addressed facility responses to the unusual incidents (a)(1) through (a)(10).
Findings:
The policy in the manual only identified the 'Compliance Officer' as the person to provide immediate response to unusual incidents. There were no procedures.
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Plan of Correction
Health Masters has completed an amended policy with procedures that addressed 715.28(a)(1-10) LICENSURE Unusual incidents.
Facility Director will be responsible for education all staff of the amendec policy and procedures, and will also be responsible for the proper execution of policy and reporting of incidents. Compliance by November 12 2008
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