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 21 through 23, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House 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.
The findings include:
Physician time sheets and census reports for the months of May, June, July and August 2012, were reviewed on August 21, 2012. There were insufficient onsite physician hours during May and July.
During the week of May 6-12, 2012, the census was 379 patients and 22.23 physician hours were documented as provided to the facility's patients during this time period. Physician hours required were 37.9 per week.
During the week of May 13-19, 2012, the census was 379 patients and 36.83 physician hours were documented as provided to the facility's patients during this time period. Physician hours required were 37.9 per week.
During the week of July 1-7, 2012, the census was 385 patients and 18 physician hours were documented as provided to the facility's patients during this time period. Physician hours required were 38.5 per week.
The findings were reviewed and confirmed with the Facility Director.
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Plan of Correction
The narcotic treatment facility will provide at least one hour of physician time per week, on site, for every ten patients by November 5, 2012.
It is the responsibility of the facility director to ensure coverage beginning November 5, 2012.
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715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on the review of patient records, the facility failed to verify the identity of the patient prior to the administration of a narcotic agent in two of five patient records.
The findings include:
Twenty patient records were reviewed on August 21 through 23, 2012. Five patient records were specifically reviewed for patient identity information. Patient records # 7 and 9 did not contain documentation of the verification of the patient's identity.
The findings were reviewed with the facility director and clinical supervisor and not disputed.
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Plan of Correction
The Admissions Department will verify the identity of all patients prior to the administration of a narcotic agent. Valid identification will include individuals identity, including name, address, date of birth, emergency contact and other identifying data.
The Senior Counselor will train all Admission Staff by September 28, 2012 on the requirements of State of PA Regulation 715.9(a)(2).
The Admissions Team will submit the valid identification to the Senior Counselor for validation prior to Admission beginning October 1, 2012.
The facility director is responsible for ensuring the training is completed and the plan is implemented by October 1, 2012 and maintained.
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715.9(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
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Observations
Based on the review of patient records, the facility failed to contact the previous narcotic treatment facility for the patient's treatment history in one of one patient records reviewed.
The findings include:
Twenty patient records were reviewed on August 21 through 23, 2012. One patient record contained information that indicated prior narcotic treatment experience and this required the facility to contact the prior narcotic treatment facility for the previous treatment history that was reported by the patient.
Patient record # 9 contained documentation the patient had received narcotic treatment services previously at other narcotic treatment programs. The facility failed to document any attempt to obtain the patient's prior treatment history from the previously attended narcotic treatment facility.
The findings were reviewed with the facility director and clinical supervisor.
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Plan of Correction
The Clinical Supervisor or designee will conduct an in-service by October 22, 2012 to educate the admissions and clinical team on the requirement and importance of contact with all previous narcotic treatment facilities prior to admission. The Clinical Supervisor or designee will remind the team of the need for a release of information to contact the previous narcotic treatment facility/s in the electronic medical record.
The Clinical Supervisor or designee is responsible for ensuring the attempted contact to the previous narcotic treatment is documented in the electronic medical record.
The facility director is responsible for ensuring the in-service is conducted by October 22, 2012 and the Clinical Supervisor or designee audits all newly admitted patient charts for the documented attempt to secure records from prior narcotic treatment facility's by October 22, 2012 |
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 exceeded 4 Pa. Code, Subsection 255.5(b) in three of six records reviewed.
The findings include:
Twenty patient records were reviewed on August 21 through 23, 2012. Six patient records were specifically reviewed for informed consents to disclose information. Patient records # 3, 9 and 10 contained signed consents to release information that exceeded 4 Pa. Code, Subsection 255.5(b).
A review of patient record # 3 revealed a consent to release information to an insurance company, signed on May 31, 2012, that exceeded 4 Pa. Code, Subsection 255.5(b). The release allowed for the information needed to transfer.
A review of patient record # 9 revealed a consent to release information to a probation officer, signed on February 1, 2012, that exceeded 4 Pa. Code, Subsection 255.5(b). The consent allowed for the release of current dose.
A review of patient record # 10 revealed a consent to release information to an insurance company, signed on January 13, 2012, that exceeded 4 Pa. Code, Subsection 255.5(b). The consent allowed for the release of current dose level, drug test results, medication history, lab work results, discharge summary, treatment plan, intake summary and financial information.
The findings were reviewed with the facility director and clinical supervisor and not disputed.
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Plan of Correction
The clinical supervisor will conduct an in-service by October 22, 2012 to reiterate the items that may be listed on any Release of Information for legal government and funding sources.
All staff must attend the annual Discovery House Confidentiality training 11/30/12 if they have not already attended the training for 2012. The clinical supervisor/designee will audit a random number of charts to ensure compliance.
The facility director is responsible for ensuring the documented in-service is completed by October 22, 2012 and protocol is followed by October 29, 2012. |
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 a review patient records, the narcotic treatment physician failed to document that the dosage levels were reviewed at least twice a year, with each review occurring at least two months apart, to determine the patient's therapeutic dosage in four of six patient records.
The findings include:
Twenty patient records were reviewed on August 21 through 23, 2012. Six patient records were reviewed for documentation from the narcotic treatment physician's review of the patient's therapeutic dosage level. Five records failed to include documentation that the narcotic treatment physician reviewed the patient's dosage level at least twice a year, # 1, 13, 14 and 16.
Documentation in patient record # 1 revealed the narcotic treatment physician conducted a dosage review on May 14, 2012. The annual physical completed on October 14, 2011, by the physician assistant included a predetermined text referring to the narcotic treatment physician: "The results of the physical examination and the annual reevaluation in this case was reviewed and/or discussed with me and includes my recommendations." This was the only dose review documented in the record from August 2011 to August 2012.
Documentation in patient record # 13 revealed the annual physical completed on October 15, 2011, by the physician assistant included a predetermined text referring to the narcotic treatment physician: "The results of the physical examination and the annual reevaluation in this case was reviewed and/or discussed with me and includes my recommendations." An order renewal was documented on June 7, 2012. This was the only dose review documented in the record from August 2011 to August 2012.
Documentation in patient record # 14 revealed the annual physical completed on September 14, 2011, by the physician assistant included a predetermined text referring to the narcotic treatment physician: "The results of the physical examination and the annual reevaluation in this case was reviewed and/or discussed with me and includes my recommendations." This was the only dose review documented in the record from August 2011 to August 2012.
Patient record # 16 revealed that a verbal order was obtained from the narcotic treatment physician. A dose review occurred on July 22, 2012. This was the only dose review documented in the record from August 2011 to August 2012.
The findings were reviewed with the facility director and clinical supervisor and not disputed.
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Plan of Correction
The facility director will provide an in-service with the medical director to reiterate the requirement for madatory twice a year dosage level reviews, with each review occurring at least two months apart to ensure the patient's therapeutic dosage by October 22, 2012.
The medical director will document the twice a year review, with each review occurring at least two months apart, to determine the patients therapeutic dosage by October 29, 2012.
The facility director is responsible for ensuring the in-service is completed by October 22, 2012 and that the random chart audits are completed to ensure ongoing compliance. |
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, the facility failed to ensure the narcotic treatment physician documented in the patient record the rationale for granting take home medication in one of five patient records.
The findings include:
Twenty patient records were reviewed on August 21 through 23, 2012. Five patient records were reviewed for take home medication documentation.
Patient # 1 had a six-day take home status. The patient was also granted split doses which meant they received two bottles for each day. The patient record revealed there was no documentation to justify the reason for the split doses. The narcotic treatment physician failed to include supporting documentation of the rationale for providing the split doses.
The findings were reviewed with the facility director and not disputed.
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Plan of Correction
The facility director will provide an in-service with the medical director to reiterate the State of PA 715.16(a)(3) regulation by October 22, 2012 to ensure the medical director understands the documentation required for take home bottle medication and split dosage.
The medical director will document the clinical rationale for providing thake home medication and/or a split dose decision by October 29, 2012.
The facility director is responsible for ensuring the in-service is completed by October 22, 2012 and that random chart audits are conducted to ensure ongoing compliance. |
715.16(f) LICENSURE Take-home priveleges
(f) An exception granted under subsection (d) shall continue only for as long as the temporary disability or exceptional circumstance exists. When a patient is permanently disabled, that case shall be reviewed at least annually to determine whether the need for the exception still exists.
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Observations
Based on the review of patient records and a review of administrative documentation, the facility failed to review annually to determine whether the need for the exception for 13-day take-home still existed.
The findings include:
Twenty patient records were reviewed on August 21 through 23, 2012. The Methadone Monitoring Questionnaire documented that three patients at the facility had 13-day take home privileges due to permanent physical disability. The patient records were reviewed for documentation that the justification for 13-day take homes still existed. Two of three records failed to include documentation that the justification for 13-day take homes still existed, specifically in patient records # 15 and 16.
The findings were reviewed with the facility director and clinical supervisor and not disputed.
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Plan of Correction
The facility director will review the State of PA 715.16(f)Regulation with the facility medical director.
The medical director will review annually, and document in the review in the electronic medical record, to determine whether the need for the exception for 13-day take-home still exists by November 5, 2012 and then at the patients annual examination.
The facility director is responsible for ensuring the medical director will complete an annual review of the need for the exception for 13-day take-home still exists by November 5, 2012 and at the patients annual physical examination. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on a review of patient records, the facility failed to ensure that the narcotic treatment physician was determining the proper dosage level for patients in one of three records reviewed.
The findings include:
Twenty patient records were reviewed on August 21 through 23, 2012. Three patient records were reviewed for initial medication orders written and signed by the narcotic treatment physician.
Patient # 9 was admitted on January 11, 2012. A face to face with the narcotic treatment physician was dated January 11, 2012. A urinalysis test was obtained with results on January 11, 2012, that was negative for opiates. The narcotic treatment physician listed a positive urine test for Morphine or other drugs as an indicator of current addiction for admission. The record did not provide a rationale for the discrepancy.
The findings were reviewed with the facility director and clinical supervisor and not disputed.
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Plan of Correction
The facility director will review the importance of accurate and timely entries into the electronic medical record with the medical director by October 22, 2012.
The medical director will acturately accurate and timely entry in the electronic medical record.
The facility director is responsible for ensuring the education is completed by October 22, 2012 and there are random chart audits to ensure ongoing compliance beginning October 29, 2012. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on review of patient records, the facility failed to ensure that each patient received an average of 2.5 hours of psychotherapy per month during the first two years, 1 hour of which shall be individual psychotherapy in one of five records reviewed.
The findings include:
Twenty patient records were reviewed on August 21 through 23, 2012. Five patient records were reviewed for the required 2.5 hours of monthly psychotherapy. Patient record # 19 failed to meet the required hours.
Patient # 19 was admitted on January 23, 2012. The average therapy hours were reviewed for May, June and July of 2012. The patient averaged 1.83 hours of psychotherapy for the three months reviewed.
The findings were reviewed with the facility director and clinical supervisor and not disputed.
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Plan of Correction
The clinical supervisor will conduct an in-service by October 22, 2012 on the State of PA 715.19(1) requirements to provide 2.5 hours of psychotherapy per month during the first two years of treatment, 1 hour of which shall by individual psychotherapy.
The clinical supervisor will conduct monthly random chart audits to ensure compliance by October 29, 2012. The clinical supervisor/senior counselor will provide documented supervision with counselors that do not meet the minimum standard.
The facility director is responsible for ensuring the in-service is completed by October 22, 2012, random chart audits are conducted monthly and supervision is provided to counselors that do not meet the minimum standard by October 29, 2012. |
715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document what materials were sent to the receiving narcotic treatment program in two of three patient records.
The findings include:
Twenty patient records were reviewed on August 21 through 23, 2012. Three records required documentation of the materials sent to the receiving provider of the transfer. Materials sent to the receiving narcotic treatment program were not documented in records # 2 and 4.
The findings were reviewed with the facility director and clinical supervisor and not disputed.
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Plan of Correction
The clinical supervisor and/or senior counselor shall conduct an in-service to educate the clinical team on how to document what materials are sent to a receiving narcotic treatment facility by October 22, 2012.
The clinical supervisor will conduct random chart audits of patient discharges by transfer to ensure the appropriate material is sent, and documented, to the receiving narcotic treatment program beginning October 29, 2012.
The facility director is responsible for ensuring the in-service is completed by October 22, 2012 and the random chart audit process begins and continues monthly beginning October 29, 2012 to ensure the problem does not recur. |
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 narcotic treatment program failed to document that it notified the referring facility of admission and initial dose of the patient in two of three patient records.
The findings include:
Twenty patient records were reviewed on August 21 through 23, 2012. Three records were reviewed for documentation of notification to the referring facility of the admission and dosing of the referred patient. Patient records # 17 and 18 were referred by another narcotic treatment program and there was no documentation that the referring facility was notified of the admission and initial dosing of the patients.
The findings were reviewed with the facility director and clinical supervisor and not disputed.
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Plan of Correction
The clinical supervisor and/or senior counselor shall conduct an in-service with the admissions team to review the State of PA 715.20(4) Regulation by October 22, 2012. The in-service will reiterate the requirementto notify the referring facility of the admission and the date of the initial dose by October 29, 2012.
The clinical supervisor will conduct random chart audits, beginning October 29, 2012, to ensure that involuntary terminations shall only be initiated if the narcotic treatment program deems that the termination wiould be in the best interest of the health or safety of the patient and others or if the patient meets the criteria of 715.21(i)(i-iv), 2.
The facility director is responsible for ensuring the in-service is completed by October 22, 2012 and the random chart audit process begins and continues monthly beginning October 29, 2012 to ensure the problem does not recur. |
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 the review of patient records, the facility failed to restrict the reasons for involuntary termination to those reasons allowed by regulation in three of four patient records.
The findings include:
Twenty patient records were reviewed on August 21 through 23, 2012. Seven records were reviewed for discharge documentation. Three records were reviewed for involuntary or administrative discharge. Two records contained documentation of the patient being discharged for reasons other than those listed by regulation. Additionally, patient # 3 was discharged immediately for reasons other than those listed by regulation.
Patient # 3 was discharged on June 6, 2012. The record revealed the narcotic treatment program discharged the patient immediately due to a change in insurance coverage.
Patient # 5 was discharged on March 30, 2012. The record revealed the narcotic treatment program discharged the patient for missing groups, missing individual sessions, missing days of dosing, positive urinalysis and recent arrests.
Patient # 7 was discharged on August 8, 2012. The record revealed the narcotic treatment program discharged the patient for attending pain management.
The findings were reviewed with the facility director and clinical supervisor and not disputed.
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Plan of Correction
The clinical supervisor and/or senior counselor shall conduct an in-service to review the elements of State of PA 715.21 Regulation by October 22, 2012. The goal of the in-service is to ensure the clinical team is aware of the procedures regarding involuntary terminations.
The clinical supervisor will conduct random chart audits, beginning October 29, 2012 to ensure thinvoluntary terminations shall only be initiated if the narcotic treatment program deems that the termination would be in the best interests of the health or safety of the patient and others or if the patient meets the criteria of 715.21(1)(i-iv), 2.
The facility director is responsible for ensuring the in-service is completed by October 22, 2012 and the random chart audit process begins and continues monthly beginning October 29, 2012 to ensure the problem does not recur. |
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 with a re-evaluation by the narcotic treatment physician in five of five patient records reviewed.
The findings include:
Twenty patient records were reviewed on August 21 through 23, 2012. Five patient records were reviewed for annual physical examinations. The facility failed to document a physical examination that had an annual reevaluation by the narcotic treatment physician in patient records # 1, 2, 11, 12 and 13. Every documentation of an annual physical examination contained the following statement documented for the patient's reevaluation: "The results of the physical examination and the annual reevaluation in this case was reviewed and/or discussed with me and includes my recommendations." There was no information documented to address the specific issues of the patient being evaluated.
The findings were reviewed with the facility director and clinical supervisor and not disputed.
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Plan of Correction
The facility director will review the State of PA 715.23(b)(5)Regulation with the clinic medical director by October 26, 2012.
The clinic medical director will ensure that the results of all annual physical examinations are completed and include the specific issues of the patient being evaluated beginning November 5, 2012.
The facility director will ensure that the Regulation is reviewed with the medical director by October 26, 2012. The facility director will audit a random sampling of charts to ensure the physical evaluation or re-evaluation is completed and there are specific issues of the patient being evaluated. The facility director audit will ensure there is no recurrance of the issue. |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on the review of patient records and administrative documentation, the facility failed to ensure the psychosocial evaluations were a clinical assessment of the historical data collected or completed within the policy of 30 days following admission in two of four patient records reviewed.
The findings include:
Twenty patient records were reviewed on August 21 through 23, 2012. Four patient records were reviewed for psychosocial evaluations. Two patient records did not document psychosocial evaluations of a clinical assessment and completed timely, # 9 and 10.
Patient # 9 was admitted January 11, 2012. The record review revealed a psychosocial evaluation had not been signed so the time frame for completion could not be determined. Also, the psychosocial document contained a repeat of the data, patient reported commentary and no clinical assessment.
Patient # 10 was admitted January 18, 2012. The record review revealed a psychosocial evaluation had not been signed so the time frame for completion could not be determined. Also, the psychosocial document contained a repeat of the data, patient reported commentary and no clinical assessment.
The findings were reviewed with the facility director and clinical supervisor and not disputed.
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Plan of Correction
The clinical supervisor and/or senior counselor shall conduct an in-service by October 26, 2012 to review elements of 715.23(b)(15) and include a clinical assessment of the historical data collected within 30 days following admission.
The clinical supervisor will conduct random chart audits, starting October 29, 2012, to ensure that the clinical assessment of the historical data collected is completed within 30 days following admission.
The facility director is responsible for ensuring the in-service is completed by October 22, 2012 and the random chart audit process begins and continues monthly beginning October 29, 2012 to ensure the problem does not recur. |
715.23(b)(22) LICENSURE Patient records
(b) Each patient file shall include the following information:
(22) Aftercare plan, if applicable.
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Observations
Based on the review of patient records, the facility failed to ensure the aftercare plan was completed in three of four patient records reviewed.
The findings include:
Twenty patient records were reviewed on August 21 through 23, 2012. Four patient records were reviewed for aftercare plans. Three patient records failed to document relevant aftercare plans, # 2, 3 and 8.
Patient # 2 was admitted May 18, 2011, and discharged as a transfer on June 6, 2012. A progress note in the record indicated an aftercare plan was completed on May 14, 2012. The documentation of the completed form could not be located..
Patient # 3 was admitted October 25, 2010, and discharged as a transfer on July 3, 2012. The last aftercare plan documented was completed on October 25, 2011, and did not address the specific issues of the discharge.
Patient # 8 was admitted on June 7, 2010, and discharged successfully on February 7, 2012. The last aftercare plan documented was completed on June 7, 2011, and did not address the specific issues of the discharge.
The findings were reviewed with the facility director and clinical supervisor and not disputed.
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Plan of Correction
The clinical supervisor and/or senior counselor shall conduct an in-service by October 22, 2012 to review elements of 715.23(b)(22) to ensure all relevant aftercare plans are completed.
The clinical supervisor or designee will conduct random chart audits by October 29, 2012 to ensure that all relevant aftercare plans are completed beginning October 29, 2012.
The facility director is responsible for ensuring the in-service is completed by October 22, 2012 and the random chart audit process begins and continues monthly beginning October 29, 2012 to ensure the problem does not recur. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on the review of patient records, the facility failed to document discharge summaries that included all of the required information in four of seven patient records reviewed.
The findings include:
Twenty patient records were reviewed on August 21 through 23, 2012. Seven patient records were reviewed for complete discharge summaries. Four patient records failed to document a discharge summary with all required components, # 2, 4, 5 and 7.
Patient # 2 was admitted May 18, 2011, and discharged on June 6, 2012. The record failed to identify an individualized reason for treatment in the discharge summary.
Patient # 4 was admitted February 6, 2012, and discharged on May 4, 2012. The record failed to identify an individualized reason for treatment and services offered in the discharge summary.
Patient # 5 was admitted August 17, 2011, and discharged on March 30, 2012. The record failed to identify services offered in the discharge summary.
Patient # 7 was admitted July 27, 2012, and discharged on August 8, 2012. The record failed to identify services offered in the discharge summary.
The findings were reviewed with the facility director and clinical supervisor and not disputed.
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Plan of Correction
The clinical supervisor and/or senior counselor shall conduct an in-service by October 29, 2012 to review the elements of 715.23(b)(23) to ensure the discharge summary contains all of the required information outlined in the State of PA Regulation.
The clinical supervisor will conduct random chart audits beginning October 29, 2012, to ensure the discharge summary contains all of the required information outlined in the State of PA regulation 715.23(b)(23).
The facility director is responsible for ensuring the in-service is completed by October 22, 2012 and the random chart audit process begins and continues monthly beginning October 29, 2012 to ensure the problem does not recur. |
715.29(4) 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.
(4) The narcotic treatment program shall maintain documentation of the Department 's approval of an exception.
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Observations
Based on the review of documentation, the facility failed to follow the exception granted by the Department allowing the counselors to exceed the 35:1 caseload.
The findings include:
The facility staffing summary report and the patient/counselor caseload list were reviewed. According to the Department's exception notice, "no more than one half of a caseload with a maximum caseload of 50 patients will be considered per counselor. Counselor Assistants may not be included in the variance." A counselor must be employed by the facility for over one year as well to be eligible for the caseload exception, #2. The facility failed to comply with this exception by allowing three of ten counselors to have over 50% of their caseload on reduced counseling hours.
Employee # 2 was assigned 39 patients at the time of the review. The counselor has been employed for less than a year with the facility. The caseload exceeded the permitted 35:1 ratio.
Employee # 6 was assigned 41 patients. The counselor was permitted to have 20 assigned patients that could have reduced counseling hours. At the time of the inspection, this counselor had 24 patients on a reduced counseling schedule. This number of patients exceeded the permissible number of clients allowed to have reduced counseling hours.
Employee # 7 was assigned 44 patients. The counselor was permitted to have 22 assigned patients that could have reduced counseling hours. At the time of the inspection, this counselor had 26 patients on a reduced counseling schedule. This number of patients exceeded the permissible number of clients allowed to have reduced counseling hours.
Employee # 8 was assigned 42 patients. The counselor was permitted to have 21 assigned patients that could have reduced counseling hours. At the time of the inspection, this counselor had 22 patients on a reduced counseling schedule. This number of patients exceeded the permissible number of clients allowed to have reduced counseling hours.
This finding was discussed with the facility director and he confirmed this finding.
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Plan of Correction
The facility director reviewed the approved Exception with the clinical supervisor on August 21, 2012.
The clinical supervisor will ensure the facility follows the Exception by reviewing the list weekly and adjusting for all admissions and discharges beginning October 29, 2012.
The facility director is responsible for ensuring the Exception is followed by October 29, 2012. The facility director will conduct random audits to check for ongoing compliance and ensure the problem does not recur. |
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 the review of patient records, the facility failed to provide supporting documentation of the reason for an exception related to a patient, # 13. Additionally, patient # 14 had a 13 day take -home status that was not approved by exception through the Department
The findings include:
Twenty patient records were reviewed on August 21 through 23, 2012. Patient # 13 received an exception due to a letter dated August 18, 2009. The documentation does not support the need and the exception has not been reviewed since 2009.
In patient record # 14 the narcotic treatment physician documented the "patient meets the 8 point criteria to 13-day take home status" on October 6, 2011. Thirteen day take home is permitted only by exception. There was no record of an exception request made to and approved by the Department to permit a thirteen day take home status to the patient.
The findings were reviewed with the facility director and clinical supervisor and not disputed.
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Plan of Correction
The clinical supervisor will provide an in-service to ensure the State of PA Regulation #715.29(5) is followed by October 19, 2012.
The facility director will review the Regulation with the facility medical director by October 22, 2012 to ensure that the facility maintains documentation of the reason for an exception in the patient's chart.
The clinical staff will complete and submit an Exception to the medical director and State of PA, when required by regulation by October 22, 2012. The medical director will shall maintain documentation of the reason for the exception in the patient's record by October 29, 2012.
The Clinical Supervisor will ensure that all required Exceptions are sent to the State of PA for review.
The facility director is will conduct a audit of a random sampling of charts to ensure the medical director has provided supporting documentation of the reason for an exception and ensure that the clinical supervisor has sent the required Exception to the State of PA for review. The audit will ensure the problem does not recur. |