INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection, methadone and buprenorphine monitoring inspections conducted on January 21-22, 2015 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 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 regarding the methadone inspection, the facility failed to provide at least one hour of physician time a week, on site for, every ten patients for nine of the seventeen weeks reviewed.
The findings include:
Physican time sheets and weekly census for the months of September, October, November and December, 2014 were reviewed on January 21-22, 2015. Seventeen weeks were reviewed. Nine weeks provided insufficient onsite physician hours during the time period reviewed.
During the week of September 1, 2014 , the patient census was 396. The facility was required to provide at least 39.60 physician hours. There were 36.81 onsite physician hours documented. The amount of onsite physician hours documented did not meet the required hours.
During the week of September 7, 2014, the patient census was 394. The facility was required to provide at least 39.40 physician hours. There were 37.24 onsite physician hours documented. The amount of onsite physician hours documented did not meet the required hours.
During the week of September 21, 2014, the patient census was 400. The facility was required to provide at least 40 physician hours. There were 37.78 onsite physician hours documented. The amount of onsite physician hours documented did not meet the required hours.
During the week of September 28, 2014, the patient census was 401. The facility was required to provide at least 40.10 physician hours. There were 39.22 onsite physician hours documented. The amount of onsite physician hours documented did not meet the required hours.
During the week of October 12, 2014, the patient census was 405. The facility was required to provide at least 40.50 physician hours. There were 39.16 onsite physician hours documented. The amount of onsite physician hours documented did not meet the required hours.
During the week of October 26, 2014, the patient census was 410. The facility was required to provide at least 41.00 physician hours. There were 38.54 onsite physician hours documented. The amount of onsite physician hours documented did not meet the required hours.
During the week of November 2, 2014, the patient census was 409. The facility was required to provide at least 40.90 physician hours. There were 38.20 onsite physician hours documented. The amount of onsite physician hours documented did not meet the required hours.
During the week of November 30, 2014, the patient census was 409. The facility was required to provide at least 40.90 physician hours. There were 39.19 onsite physician hours documented. The amount of onsite physician hours documented did not meet the required hours.
During the week of December 14, 2014, the patient census was 411. The facility was required to provide at least 41.10 physician hours. There were 38.58 onsite physician hours documented. The amount of onsite physician hours documented did not meet the required hours.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
715.6(d) LICENSURE
Physician Staffing:
Some of the Physician hours were off site phone calls and computer work during the past year. Beginning the week of February 2, 2015, the Physician will provide the required on-site hours. The Physician is responsible for providing these hours. The Physician's Assistant and Certified Registered Nurse Practitioner are responsible for providing the remaining 2/3 of the required hours. The Program Director is responsible for monitoring and approving the hours spent on-site.
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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 the review of administrative documentation regarding the methadone inspection, the facility failed to document that the physician provided one-third of all required narcotic treatment physician time for seventeen of the seventeen weeks reviewed.
The findings include:
Physician time sheets and weekly census for the months of September, October, November and December, 2014 were reviewed on January 21-22, 2015. Seventeen weeks were reviewed. Seventeen weeks did not document that the narcotic treatment physician(s) provided one-third of the required time.
During the week of September 1, 2014, the patient census was 396. The facility was required to provide at least 39.60 physician hours. One-third of the narcotic treatment physician(s) hours required were 13.20. The narcotic treatment physician ' s documented onsite hours were 10.50.
During the week of September 7, 2014, the patient census was 394. The facility was required to provide at least 39.40 physician hours. One-third of the narcotic treatment physician(s) hours required were 13.10. The narcotic treatment physician ' s documented onsite hours were 11.
During the week of September 14, 2014, the patient census was 397. The facility was required to provide at least 39.70 physician hours. One-third of the narcotic treatment physician(s) hours required were 13.23. The narcotic treatment physician ' s documented onsite hours were 11.
During the week of September 21, 2014, the patient census was 400. The facility was required to provide at least 40 physician hours. One-third of the narcotic treatment physician(s) hours required were 13.33. The narcotic treatment physician ' s documented onsite hours were 11.
During the week of September 28, 2014, the patient census was 401. The facility was required to provide at least 40.10 physician hours. One-third of the narcotic treatment physician(s) hours required were 13.07. The narcotic treatment physician ' s documented onsite hours were 11.50.
During the week of October 5, 2014, the patient census was 4053. The facility was required to provide at least 40.30 physician hours. One-third of the narcotic treatment physician(s) hours required were 13.43. The narcotic treatment physician ' s documented onsite hours were 10.50.
During the week of October 12, 2014, the patient census was 405. The facility was required to provide at least 40.50 physician hours. One-third of the narcotic treatment physician(s) hours required were 13.07. The narcotic treatment physician ' s documented onsite hours were 11.50.
During the week of October 19, 2014, the patient census was 408. The facility was required to provide at least 40.80 physician hours. One-third of the narcotic treatment physician(s) hours required were 13.60. The narcotic treatment physician ' s documented onsite hours were 12.
During the week of October 26, 2014, the patient census was 410. The facility was required to provide at least 41.00 physician hours. One-third of the narcotic treatment physician(s) hours required were 13.60. The narcotic treatment physician ' s documented onsite hours were 12.
During the week of November 2, 2014, the patient census was 409. The facility was required to provide at least 40.90 physician hours. One-third of the narcotic treatment physician(s) hours required were 13.63. The narcotic treatment physician ' s documented onsite hours were 11.50
During the week of November 9, 2014, the patient census was 407. The facility was required to provide at least 40.70 physician hours. One-third of the narcotic treatment physician(s) hours required were 13.50. The narcotic treatment physician ' s documented onsite hours were 11.50
During the week of November 16, 2014, the patient census was 407. The facility was required to provide at least 40.70 physician hours. One-third of the narcotic treatment physician(s) hours required were 13.56. The narcotic treatment physician ' s documented onsite hours were 12
During the week of November 23, 2014, the patient census was 410. The facility was required to provide at least 41 physician hours. One-third of the narcotic treatment physician(s) hours required were 13.66. The narcotic treatment physician ' s documented onsite hours were 12.
During the week of November 30, 2014, the patient census was 409. The facility was required to provide at least 40.90 physician hours. One-third of the narcotic treatment physician(s) hours required were 13.63. The narcotic treatment physician ' s documented onsite hours were 11.50
During the week of December 7, 2014, the patient census was 409. The facility was required to provide at least 40.90 physician hours. One-third of the narcotic treatment physician(s) hours required were 13.63. The narcotic treatment physician ' s documented onsite hours were 12.
During the week of December 14, 2014, the patient census was 411. The facility was required to provide at least 41.10 physician hours. One-third of the narcotic treatment physician(s) hours required were 13.70. The narcotic treatment physician ' s documented onsite hours were 12.
During the week of December 21, 2014, the patient census was 408. The facility was required to provide at least 40.80 physician hours. One-third of the narcotic treatment physician(s) hours required were 13.60. The narcotic treatment physician ' s documented onsite hours were 12.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
715.6(e)
Physician Staffing:
Some of the Physician hours during the past year were off site phone calls and computer work. Beginning the week of February 2, 2015, the Physician will provide the required 1/3 of hours with the PA and CRNP providing the remaining 2/3. The Physician is responsible for providing these hours. The Program Director is responsible for monitoring and approving the hours. |
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 the review of buprenorphine patient records, the facility failed to document a complete initial drug-screening urinalysis for each prospective patient in four of four patient records.
The findings include:
Sixteen patient records were reviewed on January 21-22, 2015. Four patient records were reviewed as buprenorphine patient records. Four buprenorphine patient records required documentation of a complete initial drug-screening urinalysis. There was no official documentation of a complete initial drug-screening urinalysis in patient records # 13, 14, 15 and 16.
Patient # 13 was admitted on November 12, 2014. Documentation provided of the initial drug-screening urinalysis was a hand written entry, dated November 18, 2014, which included a check list of drugs. The drugs on the list were then checked as positive or negative for that drug. There was no official documentation of a completed initial drug-screening urinalysis provided.
Patient # 14 was admitted on November 20, 2014. Documentation provided of the initial drug-screening urinalysis, was a hand written entry, dated November 25, 2014, which included a check list of drugs. The drugs on the list were then checked as positive or negative for that drug. There was no official documentation of a completed initial drug-screening urinalysis provided.
Patient # 15 was admitted on December 3, 2014. Documentation provided of the initial drug-screening urinalysis, was a hand written entry, dated December 9, 2014, which included a check list of drugs. The drugs on the list were then checked as positive or negative for that drug. There was no official documentation of a completed initial drug-screening urinalysis provided.
Patient # 16 was admitted on January 6, 2015. Documentation provided of the initial drug-screening urinalysis, was a hand written entry, dated January 11, 2015, which included a check list of drugs. The drugs on the list were then checked as positive or negative for that drug. There was no official documentation of a completed initial drug-screening urinalysis provided.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
715.14(a)
Urine testing:
Previously the Suboxone Program nurse had recorded in writing results of the dipstick tests. Records of each initial and ongoing urine dipstick test completed for patients in the program are now being photocopied and maintained on file at the clinic. The program nurse is responsible for performing the dipstick tests and photocopying them before disposing of the dipstick. The Administrative Assistant is responsible for maintaining the records of the test results. |