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 4-6, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House Cu - 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 and a plan of correction is due on September 8, 2009.
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Plan of Correction
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715.6(a)(3)(i) LICENSURE Physician staffing
(a) A narcotic treatment program shall designate a medical director to assume responsibility for administering all medical services performed by the narcotic treatment program.
(3) The medical director 's responsibilities include the following:
(i) Supervision of narcotic treatment physicians.
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Observations
Based on the review of administrative documentation, the facility failed to include in the medical director's responsibilities, supervision of narcotic treatment physicians.
The findings include:
The policy and procedure manual was reviewed on August 4, 2009. The job description for the medical director was reviewed on August 5, 2009. The policy and procedure manual did not include documentation of anyone providing supervision to narcotic treatment physicians. The medical director's job description did not include supervision of the other narcotic treatment physicians as part of the medical director's responsibilities.
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Plan of Correction
The Program Director will ensure that the medical directors job description includes supervision of other narcotic treatment physicians as part of the medical directors responsibility. The policy manual will also include documentation of of who is providing supervision to the narcotic treatment physicians. Is is the sole responsibility of the Program Director to amend the policy to be in compliance with the state regulations. |
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 and census reports for the months of March, April, May, June and July 2009 were reviewed on August 4, 2009. There were insufficient onsite physician hours during May and June.
During the week of May 10-16, 2009, the census was 364 patients with 32 physician hours provided.
During the week of May 24-30, 2009, the census was 365 patients with 35.5 physician hours provided.
During the week of June 21-26, 2009, the census was 372 patients with 35.5 physician hours provided.
During the week of June 28 to July 4, 2009, the census was 371 patients with 31.5 physician hours provided.
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Plan of Correction
An inservice was held by the Program Director for the narcotic treatment physician explaining the importance of providing sufficient physician hours. The Program Director will monitor hours daily to ensure there are enough physician hours for each week for compliance. |
715.8(2) LICENSURE Psychosocial Staffing
A narcotic treatment program shall comply with the following staffing ratios as established in Chapter 704 (relating to staffing requirements for drug and alcohol treatment activities):
(2) Counselor assistants. A counselor assistant eligible for a counseling caseload may be included in determining FTE ratios.
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Observations
Based on the review of administrative documentation and staff interviews, the facility failed to ensure the counselor assistant was eligible prior to assigning a full caseload.
The findings include:
The patient caseload for each clinician was reviewed on August 4, 2009. The caseload for the counselor assistant was recorded as being 35 patients. The supervision notes for the counselor assistant were reviewed on August 5, 2009. There was no documentation of a positive assessment of the counselor assistant's skill level indicating he/she was eligible for a full caseload.
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Plan of Correction
The program Director will do a training with the Clinical Supervisor to ensure proper documentation is on file prior to signing a full case load to a counselor assistant. The Program Director will monitor caseload weekly ensuring that the cs assistant has only 34 patients asigned to her case load. |
715.9(a)(4) 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:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on the review of patient records, the facility failed to ensure a determination of current physiologic dependency and at least one year physiologic dependency in four of eight patient records.
The findings include:
Twenty patient records were reviewed on August 4-6, 2009. Eight patient records required the physician to document in the patient's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
Patient record # 10 contained a document used by the physician to determine if the evidence of a one year history of addiction and current dependency was evident. This document listed "not applicable" as evidence of the one year history of addiction and "patient statement" as evidence of current dependency.
Patient record # 12 included documentation that the patient was admitted on September 23, 2008. The documentation of the patient's current dependency and one year history was dated September 29, 2008. The patient was administered the agent on September 23, 2009, six days prior to documentation of the one year history of addiction and current dependency.
Patient records # 14 and 15 included documentation of current dependency and a one year history of addiction, however, the documentation consisted of "patient statement" as evidence of current dependency and "not applicable" for evidence of the one year history of addiction.
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Plan of Correction
The Program Director held an inservice for the physicians to ensure they document 1 yr addiction in each patient file prior to admission. I will also review with the physicians that the documentation of addiction in each patient history needs signed the same day as the documentation of addiction is completed. The Program Director will monitor each new admission to ensure the documentation of addiction is completed prior to admission to ensure compliance. |
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 patient records, the narcotic treatment program failed to document, within three months after the termination of pregnancy, whether or not the patient should continue maintenance or receive detoxification treatment in one of one patient record.
The findings include:
Twenty patient records were reviewed August 4-6, 2009. An evaluation of the patient's treatment status within three months after termination of pregnancy was required in one patient record, # 17. The narcotic treatment program, specifically the physician, did not document this evaluation that was due by April 2009 based on the patient's termination of pregnancy in January 2009.
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Plan of Correction
The Program Director held trainings with the medical staff to ensure the physician will evaluate all post pregnant patients and document assessment. A hard hold will be placed on post pregnant females to ensure an evaluation is done. This will be the responsibility of the nursing staff. Program Director will monitor for 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 observation by the licensing specialist during the monitoring visit and a physical plant walk-through, the facility failed to ensure patient counseling was private and confidential.
The findings include:
The physical plant walk through was conducted in full on August 4, 2009 at about 9:30 AM. On August 5, 2009, at about 9:00 to 11:30 AM, it was observed by the licensing specialist that clinicians were discussing issues with patients in the hall area. In addition, throughout the three day monitoring, counseling sessions and telephone conversations were heard through the walls to the offices on either side of the office being occupied by the licensing specialist.
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Plan of Correction
A training was held by the Program Director and Clinical Supervisor to ensure that clinicians do not discuss patient issues in the hallways. The Program Director will purchase sound machines to ensure no telephone conversations or counseling sessions are heard through the walls. The Program Director will be responsible for purchasing the devices and making sure the devices are on. |
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, the facility failed to obtain a complete urine drug screen prior to the administration of methadone, a narcotic agent in one of three patient records.
The findings include:
Twenty patient records were reviewed on August 4-6, 2009. Three were required to have a completed urine drug screen prior to the administration of methadone.
Patient record # 10 was admitted on July 6, 2009. A urine drug screening specimen was obtained on July 6, 2009. The results were posted for the facility to review on July 8, 2009. The patient was administered 20 mg of methadone on July 7, 2009.
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Plan of Correction
Program Director will hold a medical training to ensure that all drug screens are in hand prior to medicating new patients. Patients may be admitted to the facility when a verbal result is obtained and documented prior to the posting of the drug screen. The nursing staff will be responsible to ensure drug screens are in hand. The Program Director will monitor each new patient to ensure drug screens are posted. |
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 physician documented his rationale for permitting take home medication in five of six patient records.
The findings include:
Twenty patient records were reviewed on August 4-6, 2009. Six patient records were reviewed for take home medication approval documentation. Five patient records (# 6, 8, 11, 12 and 15), did not have the physician's rationale for his granting take-home medication, but rather a statement that the take home request was approved by the management team. There was no documentation of who was part of the management team.
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Plan of Correction
The Program Director held a training with the Medical Director to ensure the physician documents his rationale for granting take home medications. The management team can not approve take homes. The Program Director will do sporadic checks to ensure the rationale is documented. |
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 the review of patient records, a procedure format, and observation and discussion with staff, the facility has failed to ensure the physician was the person to determine the patient's dose.
The findings include:
Twenty records were reviewed on August 4-6, 2009. A document that was identified by the director as a format the physician had requested clinicians use when a patient was requesting a dose increase. The format contained language allowing for the clinician to ask for a specific dose, rather than just informing the physician of the patient's request for a dose increase or decrease, after describing signs and symptoms of the patient. Patient record # 18 contained documentation of the counselor recommending a 5 milligram dose increase on June 11, 2009.
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Plan of Correction
The Program Director and Clinical Supervisor held a training on documenting the signs and symptoms of the patient for a medication increase. No recommendations will be documented, only the physician will document his approval or disapproval. The Program Director will do sporadic checks to ensure compliance. |
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 the review of patient records, the facility failed to document what materials were sent to the receiving facilities in two of two patient records.
The findings include:
Twenty patient records were reviewed on August 4-6, 2009. Two records required documentation of the material sent to the receiving facility. Records # 14 and 15 did not have documentation of the material sent to the receiving facility when the patients were transferred.
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Plan of Correction
The Program Director and Clinical Supervisor completed trainings to ensure that there is proper documentation of the material sent to the receiving facility. The Clinical Supervisor will monitor through discharge audits. The Program Director will monitor to ensure compliance. |
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 administrative documentation, the facility failed to restrict the reasons for involuntary termination to those areas allowed by regulation.
The findings include:
The patient handbook was reviewed on August 6, 2009. Involuntary administrative termination was discussed on page 20. The reasons the facility could involuntarily terminate a patient included a statement "you violate the program rules" without being specific. On page 21 and 22 there was a discussion of what the program rules were. These rules exceeded what the regulations allow for involuntary termination, including having weapons on the property, wearing hats or sunglasses at the dosing window, loitering, and paying the fee on time.
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Plan of Correction
The Program Director will amend the patient handbook to ensure that patient rules do not exceed what the regulations allow for involuntary termination (including having weapons on the property, wearing hats or sunglasses at the dosing window, loitering, and paying the fee on time). The Program Director is responsible for amending the policy.The Program Director will also review the changes with the staff. The Program Director will also monitor all discharges. |
715.23(b)(14) LICENSURE Patient records
(b) Each patient file shall include the following information:
(14) Case consultation notes regarding the patient.
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Observations
Based on the review of case consultations, the facility failed to document complete case consultations in five of seven patient records.
The findings include:
Twenty patient records were reviewed on august 4-6, 2009. Seven patient records were reviewed for documentation of case consultations. Five patient records failed to contain complete case consultations.
Patient record # 3 failed to include a disposition based on the summary for the annual case consult dated 11-12-08.
Patient record # 4 failed to document any information of the patient for the prior year during the annual case consultation dated 7-1-09.
Patient record # 7 failed to include who was present for the consultation and failed to document a disposition based on the summary for the annual case consultation dated 6-10-09.
Patient record # 11 failed to include who was present for the consultation and the disposition did not reflect that it was based on the summary for the quarterly case consultations dated 4-1-09 and 6-29-09.
Patient record # 12 failed to include a disposition for the 6-29-09 case consultation.
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Plan of Correction
The Program Director and Clinical Supervisor held an in-service discussing the case consultations and proper documentation needed for the case consult. Each consultation will include disposition information and patient information for the prior year, who was present for the consultation, and assessment of the patient. The Clinical Supervisor will monitor for compliance. The Program Director will do sporadic checks to ensure compliance. |
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 a review of patient records, the facility failed to document a complete aftercare plan in 1 of 1 records.
The findings include:
Twenty patient records were reviewed on August 4-6, 2009. One record required an aftercare plan. Record # 13 was discharged as having completed treatment and did not have an aftercare plan or documentation of the patient refusing an aftercare plan
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Plan of Correction
The Program Director and Clinical Supervisor held a training to ensure that every patient has an aftercare plan upon discharge or documentation of the patient refusing an aftercare plan. The Clinical Supervisor will monitor to ensure patients have aftercare plans. The Program Director will do sporadic checks to ensure compliance. |
715.23(d)(1) 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.
(1) The treatment plan shall identify the behavioral tasks a patient shall perform to complete each short-term goal.
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Observations
Based on the review of patient records, the facility failed to identify the behavioral tasks for the patient to perform to complete the identified treatment plan goals in four of four patient records.
The findings include:
Twenty patient records were reviewed on August 4-6, 2009. Four patient records were reviewed for documentation of the behavioral tasks the patient was to perform to complete the goals identified. Instead, the action steps reflected what interventions the clinician was going to perform.
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Plan of Correction
The Program Director and Clinical Supervisor has held an inservice to ensure that all staff are equally aware of the changes ofmaking sure the patient's behavioral tasks are well documented on the treatment plan so the patient is able to complete the goals identified. The Clinical Supervisor will monitor that the behavioral tasks are in place prior to signing for her approval. The Program Director will do sporadic checks to monitor compliance. Noncompliance in this area will result in the treatment plan not being approved by the clinical supervisor and will be sent back to the clinicain to be redone. |
715.23(d)(2) 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.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Based on the review of patient records, the narcotic treatment program failed to document treatment plan updates reflecting goal progress in five of five patient records.
The findings include:
Twenty patient records were reviewed on August 4-6, 2009. Treatment plan updates were reviewed in five patient records. The narcotic treatment program did not document in the treatment plan updates the patient's progress in relationship to the stated goals in patient records # 8, 11, 12, 15 and 17.
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Plan of Correction
The Program Director and Clinical Supervisor held trainings to ensure that treatment plans have updates of the patient's progress in relationship to the stated goals. The Clinical Supervisor will monitor prior to approval of the plan. The Program Director will do sporadic checks to ensure compliance. |