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 18- 20, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House Ha 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 24, 2008.
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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 a review of the narcotic treatment physicians' schedules on August 18, 2008, the narcotic treatment program failed to provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients.
Findings:
An assessment of physician hours for the week of May 15, 2008 revealed that the narcotic treatment physicians' hours totaled 37.22 hours. This was based on 20 physician hours and 17.22 certified registered nurse practitioner hours. The average active patient census was 390 which required at least 39 hours of physician services for the week.
An assessment of physician hours for the week of May 26, 2008 revealed that the narcotic treatment physicians' hours totaled 34.73 hours. This was based on 20 physician hours and 14.73 certified registered nurse practitioner hours. The average active patient census was 390 which required at least 39 hours of physician services for the week.
An assessment of physician hours for the week of June 8, 2008 revealed that the narcotic treatment physicians' hours totaled 28.98 hours. This was based on 14 physician hours and 14.98 certified registered nurse practitioner hours. The average active patient census was 390 which required at least 39 hours of physician services for the week.
An assessment of physician hours for the week of June 15, 2008 revealed that the narcotic treatment physicians' hours totaled 33.20 hours. This was based on 19 physician hours and 14.20 certified registered nurse practitioner hours. The average active patient census was 390 which required at least 39 hours of physician services for the week.
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An assessment of physician hours for the week of July 7, 2008 revealed that the narcotic treatment physicians' hours totaled 37.10 hours. This was based on 18 physician hours and 19.10 certified registered nurse practitioner hours. The average active patient census was 388 which required at least 38.8 hours of physician services for the week.
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An assessment of physician hours for the week of July 14, 2008 revealed that the narcotic treatment physicians' hours totaled 31.25 hours. This was based on 20 physician hours and 11.25 certified registered nurse practitioner hours. The average active patient census was 384 which required at least 38.4 hours of physician services for the week.
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Plan of Correction
The Program Director will provide training to the medical Director and the CRNP to ensure that the medical hours are being met. The Program Director will also obtain a contract with a local medical agency to ensure coverage when CRNP hours are in Question. The program Director will oversee to ensure compliance. The training and Contract will be obtained within 90 days. |
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 twelve patient records on August 18 through 20, 2008, six were required to have documented monthly urine drug screens. The narcotic treatment program failed to document monthly urine drug screens in one of six patient records.
Findings:
There was no documentation of a urinalysis drug screed for the month of April 2008 in patient record #11.
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Plan of Correction
The Medical Director and Charge nurse will complete a checklist of all patients who provided a urinalysis drug screen before the last week of the month to ensure all patients receive a urine drug screen. The Director will review to ensure compliance. This will be completed within 30 days. |
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 a review of twelve patient records on August 18 through 20, 2008, seven were required to contain documentation demonstrating that the narcotic treatment program provided each patient with an average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment. The narcotic treatment program failed to demonstrate that each patient was provided an average of 2.5 hours of psychotherapy per month in four of seven patient records where required.
Findings:
Patient record #4 was missing documentation of the required 2.5 hours of psychotherapy for the month of July 2008.
Patient record #5 revealed that the patient only received 2 hours of psychotherapy for the month of June 2008.
Patient record #9 revealed that the patient only received 2 hours of psychotherapy for the month of June 2008.
Patient record #11 revealed that the patient received no hours of psychotherapy for the month of February 2008, 1.75 hours for the month of March 2008 and 1.5 hours for the month of April 2008.
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Plan of Correction
An in service training will be held by the clinical supervisor to ensure that each patient receives a minimum of 2.5 hours of psychotherapy per month. Counseling hours will be reviewed with counselors during supervision to address deficiencies and create action plans. This will be monitored by the clinical supervisor and the Program director through chart audits to ensure compliance. This plan of action will take place within 30 days. |
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 twelve patient records on August 18 through 20, 2008, two patient records were required to contain documentation that the receiving narcotic treatment program 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. The narcotic treatment program failed to notify the transferring program of the patient's admission and initial dose date in one of two patient records where required.
Findings:
Patient record #9 was missing documentation indicating that the narcotic treatment program notified the transferring program of the patient's admission and date of initial dose.
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Plan of Correction
The nursing dept. will be trained on how to properly document confirmation of dose and notification of transferring patient. Documentation will be placed in the patient chart by the nurse manager. The nurse manager and Director will monitor through chart audits to monitor compliance. Training will take place within 30 days. |
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 a review of twelve patient records on August 18 through 20, 2008, two patient records were required to demonstrate that the involuntary termination of the patient was initiated only when all other efforts to retain the patient in treatment had failed. The narcotic treatment program failed to demonstrate that all efforts to retain the patient in the program had failed prior to initiating an involuntary termination in one of two patient records.
Findings:
A review of patient record #12 revealed that the patient was terminated from the program due to financial non-compliance. The patient had his first individual session on March 25, 2008. On March 31, 2008 the program placed the patient on an administrative detox for an inability to pay. There was no contract for negotiating payment with the patient. The treatment plan contained no objectives for addressing the patient's inability to pay. The progress notes were missing documentation demonstrating efforts made by the narcotic treatment program to retain the patient in treatment.
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Plan of Correction
The Program Director and Clinical Supervisor will provide a training to staff on policies and procedures regarding involuntary terminations which shall include documenting referral sources provided, payment plan options, and financial treatment planning. All involuntary terminations will be reviewed by the Program Director and Medical Director to ensure policy was followed. Program Director will monitor through chart audits to ensure compliance. The training will take place within 30 days. |
715.23(b)(19) LICENSURE Patient records
(b) Each patient file shall include the following information:
(19) Referrals to other projects or services.
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Observations
Based on a review of twelve patient records on August 18 through 20, 2008, five patient records were required to have referrals to other projects or services. The narcotic treatment program failed to include referral information in two of five records where required.
Findings:
Patient record #11 failed to include documentation of a referral for psychiatric services for a diagnosed but untreated mental health disorder.
Patient record #12 failed to include documentation of a referral for economic services to assist the patient with financial difficulties.
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Plan of Correction
The Clinical Supervisor will hold trainings to ensure that each patient chart shall include referrals to other projects or services. The clinical supervisor will monitor through chart audits to ensure compliance and the program director will oversee by conducting random chart audits to ensure compliance. This will be completed within 60 days. |
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 a review of twelve patient records on August 18 through 20, 2008 , two patient records were required to have a treatment plan with identified behavioral tasks for the patient to perform to complete each short-term goal. The narcotic treatment program failed to identify behavioral tasks in the treatment plan in one of two records where required.
Findings:
Patient record #11 contained a treatment plan with short-term goals, but the treatment plan failed to identify the behavioral tasks the patient needed to perform.
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Plan of Correction
The clinical supervisor will provide an in service training on treatment plan goals to include tasks to be performed by the patient. The clinical supervisor will monitor via chart audits and during individual supervision to ensure compliance. The Program Director will also conduct random Chart reviews to ensure compliance. This will be completed within 60 days. |
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 a review of twelve patient records on August 18 through 20, 2008, five patient records were required to have treatment plan updates. The narcotic treatment program failed to review, reevaluate, modify and update treatment plans in two of five records where required.
Findings:
Patient record #4 failed to address the patient's progress as it relates to the goals on the treatment plan. The short and long-term goals were only reiterated with no other explanation.
Patient record #11 contained new short-term goals, but failed to include specific behavioral tasks for the patient to perform in order to complete the goals.
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Plan of Correction
A Series of trainings will be held with all clinical staff by the Clinical Supervisor and Program Director on creating and updating treatment plans. Clinical Supervisor will monitor before approving treatment plans to ensure compliance. This will be completed within 30 days. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on a review of unusual incidents on August 18, 2008, the narcotic treatment program failed to file a written Unusual Incident Report with the Department following an unusual incident.
Findings:
A review of patient record #5 revealed that the patient allegedly overdosed on benzodiazepines on or about March 17, 2008. No follow-up was conducted by the program to confirm the patient's cause of death. In addition, the program failed to file the unusual incident with the Department.
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Plan of Correction
Program Director will train all staff on Unusual Incident reporting which will include the importance of informing Program Director of any reported deaths of a patient. Program Director or Program Manager will run daily discharge reports and incident reports to ensure all deaths or unusual incidents are reported to Department of Health and documented in the patient chart. Program Director or Program Manager will be responsible to report all unusual Incident reports to Department within 48 hours. This will be reviewed by Program Director and Clinical Supervisor during discharge Audits. Training will take place within 30 days. |
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 a review of twelve patient records on August 18 through 20, 2008, two patient records were required to document quarterly callbacks and reviews of the take home medications. The narcotic treatment program failed to conduct and document quarterly callbacks and reviews for patients with 6 day take home bottles in one of two records where required.
Findings:
Patient record #6 was missing documentation of a quarterly review for the first quarter of 2008. In addition, no quarterly callback was conducted for the second quarter of 2008.
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Plan of Correction
The Clinical Supervisor and Charge Nurse will provide Training on Call back procedures. The primary Counselor will complete call backs and document them in the patient chart. The program Director and Clinical Supervisor will review six day status patients and completed call backs during chart audits on a monthly basis to ensure compliance. This will take place within 60 days. |