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 May 21 through May 23, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House-CU 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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715.11 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 review of patient records, the facility failed to maintain confidentiality of patient records in accordance with 42 CFR 2.22 and and exceeded the parameters of 4 Pa. Code 255.5 in six of thirteen patient records.
The findings include:
Twenty-nine patient records were reviewed on May 21 through May 16, 2012. Thirteen patient records were reviewed for confidentiality of patient records in accordance to 42 CFR 2.22, and 4 Pa. Code 255.5. The facility failed to ensure that confidentiality was maintained in six of thirteen records reviewed.
Patient # 5 was admitted on October 1, 2008 and was discharged on February 28, 2012. The patient transferred to another methadone clinic. The facility released the patient's intake and psychosocial evaluation, physical exam, TB test results, to the transferring facility. However, the facility did not have consent from the patient to release that information. The consent to release the patient signed failed to address those areas.
Patient # 6 was admitted on September 21, 2009 and was discharged on March 2, 2012. On February 21, 2012, the facility faxed a release of information to another medical facility for the patient to sign and date. The release the facility faxed over already had the date completed and the witness signature filled in on the consent form. The release should have had the witness signature and date of the person who actually witnessed the consent being signed. The facility also released the physical examination to this clinic when it was not an item listed on the consent to release signed by the patient.
Patient # 8 was admitted January 19, 2012 and discharged on February 9, 2012. The record contained a consent to release for a government agency and insurance company that exceeded 4 Pa. Code 255.5. The releases allowed for the medication history, current dose level, lab work results, treatment plan, discharge summary and intake summary to be released.
Patient # 14 was admitted on September 19, 2008. The record included a consent to release for a community agency that exceeded 4 Pa. Code 255.5. The release allowed for the release of the patient's current dose and level. The purpose for the release was for mileage reimbursement.
Patient # 23 was admitted February 9, 2012. The record included a consent to release for a community agency that exceeded 4 Pa. Code 255.5. The release allowed for the release of the patient's current dosing history and medication history. The purpose for the release was for mileage reimbursement.
Patient # 24 was admitted on February 28, 2012. The record included a consent to release for an insurance company that exceeded 4 Pa. Code 255.5. The release allowed for the patient's medication, current dose, lab work, treatment plan, drug test results, discharge summary and intake summary.
Patient # 29 was admitted on July 30, 2009. The record documented the facility nurse confirmed the patient's dose to another methadone clinic on January 20, 2012. There was not a current consent to release for the methadone clinic in the patient record; the consent in the patient record had expired.
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Plan of Correction
A training was held on 5/23/12 by the program director and clinical supervisor regarding the importance of confidentiality, effective immediately the facility will maintain patient confidentiality in accordance with 42 CFR 2.22and Pa code 255.5. Each patient release will meet 42 CFR 2.22 and Pa code 255.5. The clinical supervisor and lead counselor will monitor releases and check the transfer paperwork to ensure confidentiality is maintained and does not exceed 42 CFR 2.22 and Pa code 255.5. The clinic director will do sporadic checks to monitor compliance. |
715.13(a) LICENSURE Patient identification
(a) A narcotic treatment program shall use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
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Observations
Based on the review of the facility's policy and procedures and observation, the facility failed to follow their policy for patient identification prior to being dosed with methadone.
The findings included:
The facility's policy and procedures were reviewed on May 21, 2012. The facility's policy stated, "The dispensing nurse will ask the following questions each time a patient presents for medication. What is your patient number? What is your first name? What is your date of birth? What was your last dose? Does the photo and signature match what is on the (computer) screen? The dispensing nurse will also verify that the answers the patient provides matches the information on the (computer) screen." The dosing procedures were observed on May 22, 2012 from 8:10 a.m. until 8:35 a.m. During this time the dispensing nurse was observed and she did not to ask the required questions when the patient presented to the window for dosing.
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Plan of Correction
A training was held on 5/23/12 by the clinical director for the medical staff regarding the importance of being compliant with the Discovery House Policy and Procedure on Administration of medications. Effective immediately the dispensing nurses will ask the following questions each time a patient presents for medication. What is your patient number? What is your first name? What is your date of birth? What was your last dose? They will also make sure this information matches the computer screen. The Program Director will monitor their compliance. |
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 the facility's policy and procedures and observation, the facility failed to follow their policy, "Administration of Medication".
The findings include:
The facility policies and procedures were reviewed on May 21 through May 23, 2012. The facility's policy on Administration of Medication stated, "To maintain safety and allow for the appropriate assessment of each patient, patients will not be allowed to have hats, sunglasses, beverages or children at the dosing window." The dosing procedures were observed on May 22, 2012 from 8:10 a.m. until 8:35 a.m. During this time the dispensing nurse was observed medicating patients. Patients # 13, 15 and 20 were observed at the dosing window wearing hats. The dispensing nurse did not ask these patients to remove their hat prior to dosing these patients.
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Plan of Correction
A training was held on 5/23/12 by the clinical director for the medical staff regarding the importance of being compliant with the Discovery House Policy and Procedure on Administration of medications. Effective immediately the dispensing nurses will comply with the policy and all patients must remove their hats, gloves, sun glasses, ect. prior to dosing. The program director and medical director will do sporadic checks to monitor compliance. |
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 transfer the required patient files in two of three patient records.
The findings include:
Twenty-nine patient records were reviewed May 21 through May 23, 2012. Three patient records required the facility to transfer specific patient files to the receiving narcotic treatment program as part of the transfer process. Two patient records did not transfer the specified files.
Patient # 28 was discharged following a transfer to another narcotic treatment facility February 29, 2012. The record failed to contain documentation of the required patient files being transferred to the receiving facility.
Patient # 6 was discharged following a transfer to another narcotic treatment facility March 2, 2012. The patient record contained documentation that the patient's physical examination was sent to the receiving facility. The facility failed to send the patient's admission date, psychosocial summary, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, as required by this regulation.
This finding was reviewed with the facility director and was not disputed.
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Plan of Correction
A training was held on 5/23/12 by the clinical supervisor and program director on the importance of sending all the required paperwork to the requesting facility. Effective 5/24/12, 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. The clinical supervisor and the lead Counselor will check to make sure all out going paperwork is correct and complete. The program director will do sporadic chcks to monitor compliance in this area.
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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 narcotic treatment program failed to document, in writing, that it notified the transferring narcotic treatment program of the admission of the patient and the initial dose given in one of four records.
The findings include:
Patient records were reviewed May 21 through May 23, 2012. Patient # 8 failed to include documentation in the record that the narcotic treatment program notified the transferring narcotic treatment program of the patient's admission and initial dose.
This finding was discussed with the facility director and was not disputed.
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Plan of Correction
A training was held on 5/23/12 by the clinical supervisor and program director on the importance of documenting, in the electronic file that the receiving narcotic treatment program notified the transferring program of the admission of the patient and the initial dose. Effective immediately the Clinical Supervisor and lead Counselor will check each transfer to make sure the documentation is completed. The program Director will do checks to monitor compliance.
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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 the review of patient records, the facility failed to document all efforts to retain the patient in the program prior to initiating an involuntary termination in one of one patient records.
The findings include:
Twenty-nine patient records were reviewed May 21 through May 23, 2012. Ten patient discharge records were reviewed. One record was reviewed for involuntary discharge.
Patient # 4 was admitted on May 4, 2009 and discharged on March 26, 2012. The discharge summary states, "Patient was placed on a 10 day administrative withdrawal after he was not complying with paying his weekly self pay obligation for several weeks after communicating that there were issues with his unemployment compensation." It also stated, "Patient was having issues with his compliance for not paying on his weekly balance. Patient also had issues with his attendance due to his finances. Patient complied with other aspects of his treatment by attending his individual sessions, assigned groups and displaying appropriate behaviors while here at the clinic." According to the treatment plan update of October 4, 2010, the patient had a new job. The treatment plan update of December 2, 2010, reported the loss of his funding source. A plan of payment for $100 per week was added to the treatment plan on August 4, 2011. On April 13, 2011, the patient's dose was 114 mg. On May 13, 2011, the patient had received bi-weekly take home doses. On August 10, 2011, the patient's dose was 109 mg and a medical note stated, "Patient has requested 5 mg decrease in preparation of leaving treatment." On August 11, 2011, the patient lost his take home schedule due to absences from dosing. On September 23, 2011, the patient received take home medication for Monday, Wednesday and Friday each week. On October 28, 2011, the patient lost the take home medication doses due to a multidisciplinary team meeting and noncompliance with program rules and regulations. On November 2, 2011, the patient signed a form to receive a voluntary medically supervised withdrawal taper. The documentation stated the "patient was given several opportunities to provide payment." An order was documented for a reduction of 11 mg per day for 9 days and the patient was given 99 mg on November 3, 2011. The patient received 89 mg on November 6, 2011. On November 7, 2011, an medical note stated the "patient to start voluntary medically supervised withdrawal. Patient was given several opportunities to provide payment." An order gave the patient 75 mg with a 14 mg decrease per day for 6 days. On November 10, 2011, the patient met with the physician. The patient was at 47 mg on November 9, 2011. The medical note stated the patient "was on medically supervised withdrawal for financial reasons but that is all fixed now so he plans to remain" in treatment with his lower dose. It was identified the patient was sick all day with sweats, chills, nausea, gastrointestinal upset with urges and cravings. It was noted the patient had not used and had not used for 2.5 years since he was in treatment. An order was written to "work with the patient to titrate to a stable dose." The dose was increased to 52 mg on November 10, 2011; 57 mg on November 11, 2011; 62 mg on November 15, 2011; 67 mg on November 17, 2011; and 70 mg on November 19, 2011.
On November 16, 2011, a financial noncompliance note stated the "counselor met with patient to discuss the outstanding balance in his account. Counselor inquired about patient's plan to make payment on his balance. Patient plans to pay $350 on November 23." The counselor assessed the patient "appears to have a plan in place to pay on his balance" with a plan to "make a payment as planned on 11/23." The note on November 18, 2011, was the same documentation as the one dated November 16, 2011. On November 23, 2011, a counselor note reported the patient was unable to make payment, would pay on 11/24. On November 28, 2011, a counselor note reported the patient was unable to pay due to the holidays.
The patient received one hour of counseling per month for December (12/28/2011), January (1/30/2012), February (2/22/2012), and March (3/20/2012). Several brief contacts occurred in March 2012 (7, 8, 9, 14, 15, 16, 19, 21, 22, and 23) reviewing the patient's financial status. On March 16, 2012, the patient was notified of treatment termination for noncompliance with his treatment plan goals. The Administrative notification of treatment termination signed by non-medical staff stated "your dose will decrease by 5.0 mg per day until 3/25/2012". On March 17, 2012, an order was written for 5 mg decrease per day from 50 mg. The patient attended daily until the end of the taper on March 25, 2012. All urine results from January 2011 until March 2012 were negative for illicit substances.
This record was discussed with the facility director and confirmed this finding.
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Plan of Correction
Effective immediately, no patient will be involuntarily discharged for financial Issues. There was a meeting held on 5/23/12 by the clinic director, regarding the importance of finding resources for the patient. The Program Director will monitor all discharges. |
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 the patient records, the facility failed to provide a personal history that included detail in the areas of family history, legal history, employment/vocational history, education history, military history, recreational history, prior treatment, client's perception of drug use, family drug abuse history and sexual history in eight of ten records.
The findings include:
Twenty-eight patient records were reviewed on May 21 through May 23, 2012. Ten patient records were reviewed for compliance with the documentation of personal histories. Eight records did not document personal histories that included all components of a personal history, specifically, patient records # 8, 11, 12, 17, 22, 23, 24, and 26.
Patient # 8 was admitted January 19, 2012. The personal history failed to include a detailed history in the areas the patient's family history, employment/vocational history, educational history, military history, and sexual history.
Patient # 11 was admitted on January 12, 2012. The personal history failed to include a detailed history in the areas of the patient's family history, employment/vocational history, educational history, and sexual history.
Patient # 12 was admitted on February 1, 2012. The personal history failed to include a detailed history in the areas of the patient's family history, legal history, educational history, and sexual history.
Patient # 17 was admitted on February 8, 2012. The personal history failed to include a detailed history in the areas of the patient's employment/vocational history, educational history, and sexual history.
Patient # 22 was admitted on January 19, 2012. The personal history failed to include a detailed history in the areas of the patient's sexual history.
Patient # 23 was admitted on February 9, 2012. The personal history failed to include a detailed history in the areas of the patient's employment/vocational history, military history, educational history, and sexual history.
Patient # 24 was admitted on February 28, 2012. The personal history failed to include a detailed history in the areas of the patient's educational history and sexual history.
Patient # 26 was admitted on May 8, 2012. The personal history failed to include a complete history in the areas of the patient's employment/ vocational history, educational history, and sexual history.
The documentation in the personal history was missing information because the form utilized facility does not allow for the counselor to elaborate on the patient's educational, employment/vocational history, military history, and sexual history. The answers that are provided are from a drop down box in the computer system.
This finding was discussed with the facility director and was not disputed.
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Plan of Correction
A training was held on 5/23/12 by the clinic director and clinical supervisor regarding the importance of providing personal history that includes detailed information in the area of family, legal, employment, vocational, educational, military, recreational, prior treatment, clients perception of drug use , family drug abuse history and sexual history. Effective 5/24/12 there will be a check list included in the intake packet for employees to follow to ensure that personal histories are detailed. Assessments will be checked by the clinical supervisor and lead counselor prior to the counselor signing on them. The clinic director will do sporadic checks to monitor compliance.
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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 the review of patient records, the narcotic treatment program failed to document complete discharge summaries within seven days of discharge in four of twelve records reviewed.
The findings include:
Twenty-nine patient records were reviewed on May 21 through May 23, 2012. Discharge summaries were required in twelve patient records. Based on the facility's policy and procedures, discharge summaries will be documented within seven days of the patient's discharge. The narcotic treatment program did not document discharge summaries within the required time frame in patient records #3, 7, 9, and 29.
Patient # 3 was admitted on October 30, 2009 and was discharged on February 18, 2012. The discharge summary was completed on February 29, 2012. The discharge summary was documented four days late.
Patient # 7 was admitted on December 1, 2009 and was discharged on January 15, 2012. The discharge summary was completed on January 30, 2012. The discharge summary was documented eight days late.
Patient # 9 was admitted June 10, 2010 and discharged on February 13, 2012. The discharge summary was completed on February 21, 2012. The discharge summary was documented one day late.
Patient # 29 was admitted on July 30, 2009 and discharged on January 23, 2012. The discharge summary was completed on January 31, 2012. The discharge summary was documented one day late.
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Plan of Correction
A training was held on 5/23/12 by the program director and clinical supervisor regarding the importance of having their services due done on time specifically the discharge summary. Effective 6/1/12,at the begining of each month each counselor will print out their services due and follow the due dates. At the begining of each week the counselor services due will be printed out by the clinical supervisor and lead counselor and highlighted and handed to each counselor. The counselor will follow the high lighted papers so their services due are done on time. The program director will monitor services due weekly to monitor compliance. |
705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on observation, the facility failed to keep the grounds of the facility safe and in good repair at all times for the safety and well-being of patients, employees, and visitors.
The findings include:
The patient and visitor's parking area was observed on May 21 through May 23, 2012. The patient and visitor's parking lot was unsafe and in poor condition at the time of inspection.
The parking lot was unsafe due to the asphalt being uneven and having over 100 potholes. Because of the size and number of potholes, it was hazardous to walk in the parking lot, and it was also difficult for drivers to avoid the potholes when driving in the parking lot.
The findings were confirmed by the facility director on May 23, 2012.
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Plan of Correction
On 5/8/12 there were three estimates sent to our home office for permanent repairs for the parking lot. Effective 7/1/2012, the parking lot will be in good repair at all times for the safety and well being of patients, employees, and visitors.The parking lot will be grated and new stone will be rolled onto the lot. The parking lot will be maintained in this fashion until approval is obtained to pave the lot. The lawn service will monitor the parking lot and report to the Program Director on a weekly basis. |