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 March 18, 19 and 20, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House PA 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 April 16, 2008.
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Plan of Correction
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715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on a review of facility documentation and staff interviews, the facility failed to increase the number of hours the physician worked to ensure that the physician provided one-third of the narcotic treatment medical time.
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Plan of Correction
This clinic was given an exception to regulation 704.12(6) towards the end of January, 2008. The Medical Director's contract was then re-drawn in March, 2008 in order for him to provide "no less than the state's required minimum weekly hours". Discovery House's census happened to exceed the medical director's hours the week of the signed contract between the medical director and the company. The medical director has since then adjusted his schedule to accomodate the increased census. |
715.8(1)(vi) 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):
(vi) Outpatients. The counseling caseload for one FTE counselor in an outpatient narcotic treatment program may not exceed 35 active patients.
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Observations
Based on a review of counselor hours and patient census, the facility exceeded the counselor to patient ratio of one full-time equivalent (FTE) counselor for every 35 active patients; specifically, the ratio was one full-time counselor for every 39 patients.
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Plan of Correction
This clinic was given an exception to regulation 704.12(6) towards the end of January, 2008. Each of our FTE counselors will have a maximum of 35 patients, unless the counselor is eligible for an increased caseload under the exception. This will be immediate and ongoing. The clinical supervisor will monitor for full compliance throughout the year. |
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 a review of 24 patient records, the facility failed to document the physician's determination of each patient's current opioid dependency and one-year history of opioid dependence; specifically, patient records #2, 16, 25 and 28 did not contain the required documentation of the physician's determination.
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Plan of Correction
The determination form is computer generated. The physician will complete the form upon admission to the clinic. This will be immediate and ongoing. Program director will monitor for full compliance throughout the year. |
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 a review of 24 patient records, the facility failed to, with patient consent, contact the previous narcotic treatment facility for the patient's treatment history; specifically, patients #5 and 11.
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Plan of Correction
We will request records from previous treatment facilities from every patient who is accepted to our clinic. This will be immediate and ongoing. The clinical supervisor will monitor for full compliance throughout the year. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
Based on a review of eight female patient records, the facility failed to fully inform each female patient of the possible risk to her and her unborn child from continued use of illicit drugs and from the use of, or withdrawal from a narcotic drug administered or dispensed by the program for comprehensive maintenance or detoxification treatment.
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Plan of Correction
A consent to treat form is used with each pregnant patient we serve that informs the patient of several factors of MMT. However, this form is currently being revised by our home office to specifically detail possible risks to the patient and her unborn child and the risks from continued use of illicit drugs. The form will also list the possible risks of the use of, or withdrawal from a narcotic drug administered or dispensed by this program. Approximate date of implimentation is 6/30/08. |
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 of 34 patient records, the facility failed to document that the physician reviewed the methadone dose levels in all the patient records. Documentation and staff interviews confirmed that the certified registered nurse practitioner had performed dose reviews at the time of each patient's annual physical evaluation. The physician countersigned the physical examination but failed to document the determination that the dose was therapeutically appropriate for the patient.
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Plan of Correction
Bi-annual dose reviews are computer generated. The physician will complete the form. This will be immediate and ongoing. Program director will monitor for full compliance throughout the year. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of 34 patient records, the facility failed to provide documentation that a consultation took place between the physician and certified registered nurse practitioner (CRNP). The CRNP completed physical examinations that were signed by both the CRNP and the physician but the patient record did not include documentation of a consultation, specifically, patients #1, 2, 5, 6, 8, 9, 10, 11, 13, 16, 17, 18, 25, 28, 29, 32, 33 and 34.
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Plan of Correction
Upon a prospective admission to our clinic, the nurse practitioner and program physician will have a verbal consultation about said patient. This consultation will also be documented in the prospective patient's electronic file. This will be immediate and ongoing. Program Director will monitor for full compliance throughout the year. |
715.16(a)(5) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(5) A narcotic treatment program shall develop written policies and procedures relating to granting and rescinding take-home medication privileges.
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Observations
Based on a review of the narcotic treatment program's policies and procedures manual, patient records and staff interviews, the facility failed to document that the decision to grant and rescind take-home privileges is the responsibility of the physician. Specifically, the facility's current policy and procedure indicated take-home status was determined by the treatment team and not the physician.
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Plan of Correction
Physician will continue being the only one to grant and recind all take-homes. This practice will be reflected in our policy and procedure manual. This will be immediate and ongoing. Program Director will monitor for full compliance throughout the year. |
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 patient records, the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment in 9 of 20 records, specifically patients # 1, 6, 9, 10, 11, 12, 17, 31 and 32. .
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Plan of Correction
The patients in question were attending two groups per month and only receiving .5 of psychotherapy per month. Patients requiring 2.5 hours of counseling per month will receive at least one hour of individual counseling per month. The implimentation of this plan will be immediate and ongoing. The clinical supervisor will monitor for compliance throughout the year. |
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 facility failed to document that they notified the transferring narcotic treatment program of the admission of a patient and the date of the initial dose in 2 of 5 records, specifically # 5 and 13.
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Plan of Correction
A notification form will be sent the day of admission to the previous treatment program. Nurse practitioner will continue to complete these forms on the day of admission and will fax the forms to the previous treatment programs. This will be immediate and ongoing. The clinical supervisor will monitor for full compliance throughout the year. |
715..23(b)(1) LICENSURE Patient records
(b) Each patient file shall include the following information:
(1) A complete personal history.
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Observations
Based on a review of patient records, the facility failed to document a complete personal history in 9 of 15 records, specifically, # 2, 5, 6, 9, 10, 11, 12, 25, and 33 as they contained one-word answers without further clarification.
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Plan of Correction
An in-service training will be provided that will address techniques of obtaining more detailed, pertinent information during the intake process. This training will be done by 5/31/08. The clinical supervisor will also address this issue during individual supervision and will provide the in-service training. The clinical supervisor will monitor for full compliance throughout the year. |
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 review of 14 patient records, the facility failed to provide an evaluative assessment by the counselor, based on the historical data obtained in records # 2, 5, 6, 9, 10, 11,12, 13, 16, 25, 28, 29, 32 and 33; specifically, documentation consisted of a repetition of the personal history and statements reported by the patient and did not contain a clinical assessment.
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Plan of Correction
An in-service training will be provided on techniques to provide appropriate clincial assessments during the intake process and how to appropriately document these assessments. The training will be done by 5/31/08. The clinical supervisor will also address this issue during individual supervision and will provide the in-service training. The clinical supervisor will monitor for full compliance throughout the year. |
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 a review of patient records, the facility failed to document a complete discharge summary in 7 of 10 records reviewed; specifically the discharge summaries for patients # 19, 20, 21, 22, 25, 27 and 28 were generic and provided minimal information regarding the patient's reasons for seeking treatment, progress in treatment and reasons for leaving treatment.
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Plan of Correction
An in-service training will be provided that will address proper ways of documenting discharges, specifically making sure the discharge information is complete and includes more information regarding the patient's reasons for seeking treatment, progress in treatment and reasons for leaving treatment. The training will be done by 5/31/08. The clinical supervisor will also address this issue in individual supervision and will provide the training. The clinical supervisor will monitor for full compliance throughout the year. |
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 develop treatment plans that contained short term goals with measurable steps. In 23 of the 23 patient records reviewed, treatment plan documentation contained vague, non-specific steps to reach the goals and the timeframes were generalized rather than realistically specific to the action step. Additionally, the treatment plans did not identify the support services that are available to the patient in their efforts to achieve treatment goals.
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Plan of Correction
An in-service training will be provided on techniques on creating excellent treatment plans that include specific steps to reach the goals and specific timeframes for the action steps. The treatment plans will additionally identify the support services that are available to the patients. The training will be done by 5/31/08. The clinical supervisor will also address this issue during individual supervision and will provide the training. The clinical supervisor will monitor for full compliance throughout the year. |
715.26(b) LICENSURE Security
(b) Each narcotic treatment program shall provide the Department with a specific plan describing the efforts it will make to avoid disruption of the community by its patients and the actions it will take to assure responsiveness to the community. This plan shall designate a staff member to act as community liaison.
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Observations
Based on a review of the narcotic treatment program's policy and procedure manual and staff interviews, the facility failed to provide the Department with a specific plan (who, what, when) describing the efforts it will make to avoid disruption of the community by its patients and the actions it will take to assure responsiveness to the community.
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Plan of Correction
The company has designated the Program Director as community liaison in our security plan. The Program Director will create a more specific plan to address our efforts to avoid disruption of the community by our patients and the actions we will take to assure responsiveness to the community. This plan will be created by 4/30/08. Program Director will monitor for full compliance throughout the year. |
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
The facility failed to maintain the counselor to patient ratio specified in the exception granted to the facility by the Division of Drug & Alcohol Licensing; specifically, six of eight counselors exceeded the patient to counselor ratio specified in the exception.
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Plan of Correction
The clinical supervisor will manage each caseload to maintain compliance with this requirement, specifically, no caseload will consist of more than 50% of reduced-schedule patients. The implimentation of this plan will be immediate and ongoing. The clinical supervisor will monitor for full compliance throughout the year. |