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 October 12-14, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Dolminis 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 and a plan of correction is due on November 16, 2010.
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Plan of Correction
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715.10(b) LICENSURE Pregnant patients
(b) A narcotic treatment program shall give pregnant patients the opportunity for prenatal care either by the narcotic treatment program or by referral to appropriate health-care providers.
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Observations
Based on the review of patient records and an interview with the clinical supervisor, the facility failed to document that pregnant patients were given the opportunity for prenatal care either by the narcotic treatment program or by referral to appropriate health-care providers in one of three patient records. The findings include:Fourteen patient records were reviewed on October 12-14, 2010. Three patient records reviewed required documentation that the program had given pregnant patients the opportunity for prenatal care. The program did not document that a patient was given the opportunity for prenatal care in patient record # 2.Patient # 2 was admitted on June 14, 2007. The patient became pregnant in January 2010. There was no documentation that the program had given the pregnant patient the opportunity for prenatal care either by the narcotic treatment program or by referral to appropriate health-care providers. There was no documentation provided that showed the patient was receiving prenatal care. An interview with the clinical supervisor on October 14, 2010 confirmed there was no documentation provided that showed the patient had been given the opportunity for prenatal care either by the narcotic treatment program or by referral to appropriate health-care providers in the above mentioned patient record.
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Plan of Correction
All pregnant patients will be given the opportunity for prenatal care either by the narcotic treatment program or by referral to appropriate health-care providers. This information will be documented in the patient's progress notes and treatment plans.
All counselors will be re-trained in this process by the clinical supervisor and documented. Further all new counselors will be trained to this process during orientation.
Compliance will be monitored through random monthly chart audits conducted by peers and clinical supervisor.
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715.10(c) LICENSURE Pregnant patients
(c) Counseling records and other appropriate patients records shall reflect the nature of prenatal support provided by the narcotic treatment program.
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Observations
Based on the review of patient records and an interview with the clinical supervisor, the facility failed to document the nature of prenatal support provided by the narcotic treatment program in one of three patient records. The findings include:Fourteen patient records were reviewed on October 12-14, 2010. Three patient records reviewed required documentation that reflected the nature of prenatal support provided by the narcotic treatment program. The program did not document the nature of prenatal support provided by the narcotic treatment program in patient record # 2. Patient # 2 was admitted on June 14, 2007. The patient became pregnant in January 2010. There was no documentation that reflected the nature of prenatal support provided by the narcotic treatment program.An interview with the clinical supervisor on October 14, 2010 confirmed there was no documentation provided that reflected the nature of prenatal support provided by the narcotic treatment program in the above mentioned patient record.
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Plan of Correction
The primary counselor will document the nature of prenatal support provided to all pregnant patients. This information will be documented in the patient's progress notes and treatment plans.
All counselors will be re-trained in this process by the clinical supervisor and documented. Further all new counselors will be trained to this process during orientation.
Compliance will be monitored through random monthly chart audits conducted by peers and clinical supervisor.
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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 dosing observation and an interview of the dosing nurses, the facility failed to physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR Part 2, Subpart B, 2.22 (relating to notice to patients of Federal confidentiality requirements) and 28 Pa. Code 709.28 (relating to confidentiality).The findings include:During the observation of the methadone dispensing on October 13, 2010 between 8:40 AM and 9:15 AM, patients were observed returning their take home bottles. The patients were observed as being responsible for crossing out their identifying information on the take home bottles. The take home bottles were placed in a general trash container in the dispensing area. An inspection of the take home bottles from the general trash container revealed that patient names remained visible on the bottle label. This practice did not ensure that the patient's confidentiality was physically secure and maintained, as required by Federal and State regulations. The dosing nurses were interviewed on October 13 , 2010. The dosing nurses reported the some patients were not crossing off their names completely. Others had used the wrong marker to cross off their names. The dosing nurses confirmed there were several take home bottles placed in the trash where the patient's identifying information was visible.
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Plan of Correction
Nursing staff will be responsible for the removal of patient identifying information on Kol containers prior to disposing them to ensure that patient confidentiality is maintained. This deficiency was immediately corrected.
Nursing staff was educated to this process as they were immediately made aware of the error.
Compliance will be monitored through random monitoring of dosing observations by the program director.
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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 a review of patient records and an interview with the facility director, the facility failed to ensure that the patient was initially dosed following the completion of a drug-screen urinalysis in one of eight patient records.The findings included:Fourteen patient records were reviewed on October 12-14, 2010. Eight patient records were reviewed for drug screen urinalysis results prior to a patient's initial dose. Per regulation, a narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter. The facility failed to document the completion of a drug screen urinalysis prior to dosing in patient record # 14.Patient # 14 was admitted into treatment on July 9, 2010. Patient # 14 received a dose of 30 mg on July 9, 2010, the same date that the patient had submitted a urine specimen for a drug-screen urinalysis. The drug-screen urinalysis results were obtained on July 10, 2010. An interview with the facility director took place on October 14, 2010 at approximately 2:00 PM, and it was confirmed that the patient had been dosed before the results of the urinalysis had been received. The facility director reported that patient # 14 was dosed prior to the urinalysis results being received due to pregnancy.
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Plan of Correction
The medical director will document all verbal confirmation results of completed drug screen urinalysis prior to prescribing a dosing order.
The medical director was educated to this change as he was present at the exit interview.
Compliance will be monitored through random medical chart audits conducted by the nursing staff and clinical supervisor.
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715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on the review of patient records and an interview with the Director of Narcotic Treatment Program Services, the facility failed to ensure that the narcotic treatment physician determined the proper dosage level in three of five patient records.The findings include:Fourteen patient records were reviewed on October 12-14, 2010. Five patient records were reviewed for the physician's documentation in determining the initial dose. Three out of five patient records, specifically, 1, 9 and 13 had standing orders documented for their initial dose. Patient # 1 received an initial dose of 30 mg. Documented in patient record # 1 was an order by the physician that included a standing order to increase to 35 mg the next day and 40 mg the day after that. There was no documentation that the narcotic treatment physician continued to assess the patient to determine if an increase in the patient's dose was needed. Patient # 9 received an initial dose of 30 mg. Documented in patient record # 9 was an order by the physician that included a standing order to increase to 35 mg to 40 mg to 45 mg maximum. There was no documentation that the narcotic treatment physician continued to assess the patient to determine if an increase in the patient's dose was needed.Patient # 13 received an initial dose of 30 mg. Documented in patient record # 13 was an order by the physician that included a standing order to increase by 5 mg daily until the patient reached 45 mg. There was no documentation that the narcotic treatment physician continued to assess the patient to determine if an increase in the patient's dose was needed.An interview with the Director of Narcotic Treatment Program Services and the Nurse took place on October 13, 2010 at approximately 2:30 p.m. and confirmed that the standing orders were documented in the patient records. It was also confirmed that the facility staff was aware of the deficiency prior to the inspection and corrective measures have already been implemented.
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Plan of Correction
The program physician will determine the appropriate dosage level for the induction of a new client. The client will remain at this dose until completing a dose assessment form and requesting an increase.
Upon receiving request, the program physician, through assessment, will adjust dosage according to determined need.
Compliance will be monitored by random monthly medical chart audits conducted by the program director.
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