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 January 8 through January 10, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House- NC, 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.
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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 services a week, on site for, every ten patients in eight of the fourteen weeks reviewed.
The findings include:
Physician time sheets for the months of October, November and December were reviewed on January 8, 2012. A total of fourteen weeks of physician time sheet documentation was reviewed. In the review of these time sheets and census information that corresponded with the time frames, it was determined there were insufficient physician hours during eight weeks that were reviewed.
During the week of September 30 through October 6, 2012, the patient census was 364. The facility was required to provide at least 36.4 physician hours. There were 16 physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of October 7 through October 13, 2012, the patient census was 366. The facility was required to provide at least 36.6 physician hours. There were 14.5 physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of October 14 through October 20, 2012, the patient census was 367. The facility was required to provide at least 36.7 physician hours. There were 22.5 physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of October 21 through October 27, 2012, the patient census was 365. The facility was required to provide at least 36.5 physician hours. There were 21.48 physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of October 28 through November 3, 2012, the patient census was 363. The facility was required to provide at least 36.3 physician hours. There were 14 physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of November 11 through November 17, 2012, the patient census was 364. The facility was required to provide 36.4 at least physician hours. There were 28.52 physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of November 18 through November 24, 2012, the patient census was 359. The facility was required to provide at least 35.9 physician hours. There were 28.03 physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of November 25 through December 1, 2012, the patient census was 361. The facility was required to provide at least 36.1 physician hours. There were 34.75 physician hours documented. The amount of physician hours documented did not meet the required hours.
This finding was reviewed with the facility director on November 8, 2013 at 10:00 a.m. and was not disputed.
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Plan of Correction
Due to our NP leaving without notice meidcal hours were short. We have now hired an NP who is filling the required hours, we also have another PA who is will to work to fill in when our regular NP is unable to do the required hours.The program Director has made a schedule of required hours per census and given a copy to the Nurse Practicioner. The Program Director will monitor the census on a weekly basis informing the nurese procticioner of the required hours each week. This will be monitored by checking time cards each week. |
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, someone other than the narcotic treatment physician documented the patient's subsequent dose and schedule in one of two records reviewed.
The findings include:
Thirty patient records were reviewed on January 8-10, 2013. Two patients were administratively terminated. The records included termination notification letters. One of the two termination notification letters documented dose change orders that were written by someone other than the narcotic treatment physician.
Patient # 9 received an administrative withdrawal notice on August 10, 2012. The notice documented the patient's dose would be decreased 4 mgs. per day until August 19, 2012. The letter was not signed by the narcotic treatment physician. The record was reviewed for documentation from the narcotic treatment physician initiating the dose change. There was no documentation in the record prior to the administrative notice being given to the patient that showed the narcotic treatment physician made the decision to decrease the patient's dose 4 mgs. per day.
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Plan of Correction
Our Home Office has added the physician signature to the Administrative Withdrawl form. This has already been instituted into our software. The form does indicate the dosage so it will be approved by the Medical Director. The program director has made sure the form was put into the clinic software. |
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 review of the patient records, the facility failed to document the results of an annual physical examination which included an annual reevaluation by the narcotic treatment physician three of six patient records.
The findings include:
Thirty patient records were reviewed on January 8 -10, 2013. Six patient records were reviewed for documentation of an annual physical examination which included a reevaluation of the patient by the narcotic treatment physician. Three of the six records reviewed did not have the narcotic treatment physician's reevaluation documented.
Patient # 12 was admitted on November 12, 2010. The annual physical examination was documented on November 30, 2012 by the Certified Registered Nurse Practitioner. The record did not include the narcotic treatment physician's reevaluation of the patient.
Patient # 23 was admitted on November 8, 2011. The annual physical examination was documented on November 16, 2012 by the Certified Registered Nurse Practitioner. The record did not include the narcotic treatment physician's reevaluation of the patient.
Patient # 25 was admitted on November 14, 2011. The annual physical examination was documented on November 17, 2012 by the Certified Registered Nurse Practitioner. The record did not include the narcotic treatment physician's reevaluation of the patient.
This finding was discussed with the medical director on January 10, 2013 and was not disputed.
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Plan of Correction
The Program Director will meet with the Medical Director and the Nurse Practicioner to go over the regulations regarding the annual physical and the Physicians reevaluation note that needs to be included. They will be informed that this can be done within the annual physical or documented in the Annual dose review referencing the annual phycial as a reevaluation. This will be monitored by the Program Director through chart audits. |
715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to document the results of laboratory tests in five of fifteen patient records, as required.
The findings include:
Thirty patient records were reviewed on January 8-10, 2013. Fifteen patient records were reviewed for the results of laboratory tests; specifically a tuberculosis Mantoux test (PPD) and Serological testing (blood work). Per regulation, each patient file shall include the results of laboratory tests or other special examinations given by the narcotic treatment program. The facility failed to document the results of a Mantoux test and Serological testing in patient records # 2, 3, 5, 15 and 29.
Patient # 2 was admitted on March 26, 2012 and discharged on September 24, 2012. There was no documentation of the results of a Mantoux test or Serological testing in patient record # 2. The record documented the patient refused the tests.
Patient # 3 was readmitted on November 23, 2012. There was no documentation of the results of a Mantoux test or Serological testing in patient record # 3. The record documented the patient had the tests in July, however, the facility failed to attempt to get the results of the tests.
Patient # 5 was readmitted on June 22, 2012. The results of Serological testing in the patient record were from September 26, 2009. There were no Mantoux test results in the record due to the physician deferring to conduct the test because the patient was pregnant.
Patient # 15 was admitted on June 13, 2012. There was no Serological testing in the patient record. The record documented the patient refused the blood work because it was recently completed at her OBGYN office, however, the facility failed to attempt to get the results. There were no Mantoux test results in the record due to the physician deferring to conduct the test because the patient was pregnant.
Patient # 29 was admitted on May 21, 2012. There was no documentation of the results of a Mantoux test or Serological testing in patient record # 29. The record documented the patient refused the tests.
This finding was discussed with facility staff and was not disputed.
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Plan of Correction
The Program Director will meet with the Nurse Practicioner and go over the regulation on the blood work and Mantoux testing what is needed in the chart and time frames. The nurse practicioner will make sure all blood work and Mantoux is obtained from other treatment centers when it has been recently done. The Program Director will monitor this for compliancethrough chart audits. |