INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use narcotic agents, specifically methadone and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on July 20-22, 2010 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 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 August 23, 2010.
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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 July 20, 2010. The job description for the medical director was reviewed on July 21, 2010. 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
Program Director will amend the Job Description of the Medical Director as well as the narcotic treatment physician to include the supervision of the narcotic treatment physician by the medical director. Program Director will provide a brief training on job duties of the medical Director and narcotic treatment physician. This will be done by the program director and it will take place within the next 30 days. |
715.6(b)(1-9) LICENSURE Physician Staffing
(b) A narcotic treatment program may employ narcotic treatment physicians to assist the medical director. A narcotic treatment physician 's responsibilities include:
(1) Performing a medical history and physical exam.
(2) Determining diagnosis and determining narcotic dependence.
(3) Reviewing treatment plans.
(4) Determining dosage and all changes in doses.
(5) Ordering take-home privileges.
(6) Discussing cases with the treatment team.
(7) Issuing verbal orders pertaining to patient care.
(8) Assessing coexisting medical and psychiatric disorders.
(9) Treating or making appropriate referrals for treatment of these disorders.
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Observations
Based on the review of administrative documentation, the facility failed to include all of the required responsibilities of the narcotic treatment physician.
The findings include:
The policy and procedure manual and physician job description were both reviewed on July 20, 2010. The physician's job description did not include assessing coexisting medical and psychiatric disorders or treating/referring for treatment of these disorders.
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Plan of Correction
Program Director will amend the Job Description of the Medical Director and Narcotic Treatment Physician to include the assessment of coexisting medical and psychiatric disorders and referring for treatment of these disorders. Program Director will provide a training to the Medical Director and narcotic treatment physician on job duties to include the assessment of coexisting medical and psychiatric disorders. This will be done by the Program Director and it will be done within 30 days. |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on the review of patient records, the facility failed to send the required information to the receiving narcotic treatment program in four of four patient records reviewed.
The findings include:
Twenty patient records were reviewed July 20-21, 2010. Four patient records were reviewed for documentation required for transfer to another narcotic treatment program.
Patient record's # 10, 11, 12 and 16 had no documentation of patient records being sent to the receiving facilities.
In addition, patient record # 11 had no consent for the receiving facility.
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Plan of Correction
A training will be provided to clinical staff on the transfer of patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient. The training will be provided by the Clinical Supervisor and Lead Counselor. The training will take place within the next 30 days. Clinical Supervisor will complete a random audit of all transfers on a quarterly basis to ensure compliance. |
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 the review of patient records, the facility failed to document that it notified the referring facility of the admission and initial dosing of the patient in five of five patient records.
The findings include:
Twenty patient records were reviewed July 20-22, 2010. Five patient records required the facility to notify the referring narcotic treatment program of the admission and date of initial dose.
Patient # 1 was admitted 3-17-2010. There was no documentation of notice to the referring facility of the admission.
Patient # 2 was admitted 7-12-2010. There was no documentation of notice to the referring facility of the admission.
Patient # 4 was admitted 7-8-2010. There was no documentation of notice to the referring facility of the admission.
Patient # 10 was admitted 3-29-2010. There was no documentation of notice to the referring facility of the admission.
Patient # 13 was admitted 4-7-2010. There was no documentation of notice to the referring facility of the admission.
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Plan of Correction
A training will be provided to Discovery House Staff on transfer policies and procedures which will include the need for the receiving narcotic treatment program to document in writing that is 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. This training will take place within the next 30 days. The Clinical Supervisor will complete a quarterly audit to ensure compliance. |
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 the review of patient records, the facility failed to complete the annual physical with a re-evaluation by the physician in five of five patient records reviewed.
The findings include:
Twenty patient records were reviewed July 20-22, 2010. Five required a re-evaluation by the physician on the annual history and physical.
Patient # 3 was admitted 12-1-08. The annual physical exam was completed on 12-22-09 by the Certified Physician Assistant (PAc), but did not include a re-evaluation by the physician.
Patient # 6 was admitted 12-27-07. The annual physical exam was completed on 12-9-09 by the Certified Physician Assistant (PAc), but did not include a re-evaluation by the physician.
Patient # 7 was admitted 5-9-08. The annual physical was completed by the Certified Nurse Practitioner (CRNP) on 4-29-10, but it did not include a re-evaluation by the physician.
Patient # 15 was admitted 5-21-09. The annual physical was completed by the Certified Nurse Practitioner (CRNP) on 4-30-10, but it did not include a re-evaluation by the physician.
Patient # 18 was admitted 4-29-03. The annual physical exam was completed on 4-12-10 by the Certified Physician Assistant (PAc), but it did not include a re-evaluation by the physician.
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Plan of Correction
The Medical Director will document via a medical note that he evaluated the annual review and physical and will document his determination whether the patient should continue MMT or begin an MSW. Program Director to provide training on this process. This will take place within 30 days. Program Director will conduct quarterly chart reviews to ensure this task is completed. |
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 the review of patient records, the facility failed to ensure the psychosocial evaluations were a clinical assessment of the historical data collected in four of five patient records.
The findings include:
Twenty patient records were reviewed on July 20-22, 2010. Five patient records were reviewed for psychosocial evaluations. Four of the psychosocial evaluations did not include an evaluation of the patient problems/needs, assets/strengths, support systems, coping mechanism, and factors that may inhibit treatment.
Patient records # 1, 2 and 4 had psychosocial documents that contained a repeat of data provided by the patient and no clinical assessment of the data collected. Patient record # 19 contained an evaluation that failed to address the actual historical data collected.
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Plan of Correction
A training will be provided to clinical staff on writing psychosocial evaluations. The training will focus on documentation of patient problems/needs, assets/strengths, support system, coping mechanism, and factors that may inhibit treatment. The training will also focus on writing an assessment of the data collected. The training will provided by the clinical supervisor and lead counselor. This will take place within the next 30 days. Clinical Supervisor and Lead counselor will ensure compliance by signing off on all psychosocial evaluations. |
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 all of the required information in five of five patient records.
The findings include:
Twenty patient records were reviewed July 20-22, 2010. Five patient records were reviewed for discharge summaries.
Patient records # 10, 11, 12, 16 and 17 did not include the reason the patients decided to enter treatment when they did. Instead, the identified reason contained a statement of opiate dependence.
Patient records # 11, 16 and 17 did not document what services were offered to the patient during the course of their treatment.
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Plan of Correction
A training will be provided to clinical staff on writing a discharge summary. The training will focus on documenting the reasons the patient decided to enter treatment as well as services offered while patient during their course of treatment. The training will provided by the clinical supervisor and lead counselor. This will take place within the next 30 days. Clinical Supervisor and Lead counselor will ensure compliance by singing off on discharge summaries. |