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 September 26, 27 and 28, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center for Behavioral Health - HA, Inc. 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 and a plan of correction is due on October 19, 2007. .
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Plan of Correction
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715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
Based on a clinical chart review, the facility failed to obtain an informed consent for the disclosure of information. In chart #19, a release of information to another methadone maintenance facility failed to provide the specific information to be disclosed. Charts #3, 10 and 13 included release forms that documented the information would be obtained from the facility, rather than released to the facility.
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Plan of Correction
Training will be conducted by clinical supervisor on having appropriate releases in place prior to releasing information. Program Director will be responsible. |
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 the clinical records and an interview with the director on September 28, 2007, the facility failed to provide the required monthly urine drug screen for all patients. Chart # 18 is missing a urine drug screen for July 2007. Chart #21 is missing a urine drug screen for April 2007.
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Plan of Correction
Program Director will reinforce to the medical associates the requirement for monthly urine testing. Program Director will be responsible. |
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 chart reviews and an interview with the director, the facility failed to provide documentation of a consultation between the prescribing physician and the medical staff who conducted the initial physical examination prior to determining the initial dose for patient records # 8, 9, 10, 11, 12, 13, 18, 19, 20, and 21.
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Plan of Correction
Medical Director and Physican assistant will be instructed by program director to document a consultation between them prior to determining the initial dose. Program Director will be responsible to monitor. |
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 a patient record review, the facility failed to send the admission date, medical and psychosocial summaries, exception requests and current status to receiving narcotic treatment program for patient #19.
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Plan of Correction
Associates will be trained by clinical supervisor on the required paperwork to be transferred from patient file at time of transfer to another nartocic treatment facility. Program Director will be responsible |
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 provide notification to the sending narcotic treatment program of patients #9 and #13 admission and date of initial dose.
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Plan of Correction
Associates will be instructed on the proper notification to the sending narcotic treatment program of admission date and initial dose. Program Director will monitor. |
715.21(1)(i-iv) 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.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
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Observations
Based on a review of patient records, the facility failed to comply with the limited number of reasons a patient may be involuntarily discharged. Patient records # 12 and # 18 were both notified of an involuntary discharge for non-payment of the bill. There was no documentation that this had been addressed as a treatment issue nor was there any indication that efforts were made to retain these patients. Additionally, the decision to involuntarily terminate patients # 12 and 18 for financial reasons was not made by the physician.
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Plan of Correction
Associates will be trained on the limited reasons a patient can be involuntarily discharged. All attempts will be made to retain patients in treatment, but if all fails and compliance not met the physican will make the decision to terminate. Program Director will monitor. |
715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on a record review and conversations with the director, the physician assistant is completing the majority of the patient physical examinations, but was not signing and dating the physical examination. Only the physician signature and date appears on the physical form for patients # 8, 9, 10, 11, 12, 13, 18, 19, 20 and 21. The person completing the examination must sign and date the examination.
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Plan of Correction
The Physician Assistant will be instructed by Program Direcort to sign and date all physicial she completes. Program Director will monitor. |
715.23(b)(22) LICENSURE Patient records
(b) Each patient file shall include the following information:
(22) Aftercare plan, if applicable.
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Observations
Based on chart reviews and a conversation with the director, the facility failed to provide a contact person and a re-entry process on the aftercare plan for patient #23.
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Plan of Correction
The clinical supervisor will train clinical staff to ensure after care plans address each of the required components, specifically, contact person and reentry process. This will be monitored by the clinical supervisor. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a chart review, the facility failed to document that the medical director reviewed and signed the annual clinical evaluation for patient #2 and #16.
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Plan of Correction
Medical Director will be instructed to sign off on all annual clinical evaluations. Clinical Supervisor will monitor. |
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 the policy and procedure, the facility failed to identify the incidents that require Departmental notification.
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Plan of Correction
The policy will be reviewed/amended as needed. The director and policy advisor from Discovery House Home Office will be responsible. |