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 February 1-3, 2011 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 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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715.10(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 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 in three of three client records.
The findings include:
Twenty seven patient records were reviewed on February 1-3, 2011. Three patient records reviewed were of female patients who must be informed of the possible risk to a mother and her unborn child. Per regulation, 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. The facility did not document that the patient was informed of the risks in patient records # 2, 16 and 17. In addition, there was no documentation that specified either the process of providing a pregnant patients with risks to self and unborn child or actual documentation of the risks.
Patient # 2, was admitted on October 15, 2010. There was no documentation that the narcotic treatment program ensured that the female patient was 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. The patient was informed only that methadone is transmitted to the unborn child and will cause physical dependence.
Patient # 16, was admitted on November 18, 2010. There was no documentation that the narcotic treatment program ensured that the female patient was 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. The patient was informed only that methadone is transmitted to the unborn child and will cause physical dependence.
Patient # 17, was admitted on July 7, 2010. There was no documentation that the narcotic treatment program ensured that the female patient was 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. The patient was informed only that methadone is transmitted to the unborn child and will cause physical dependence.
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Plan of Correction
The Medical Director 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 whthdrawl from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment. Each female patient shall be informed prior to admission and consent to narcotic treatment. The patient's consent to narcotic treatment and their acknowledgement of the potential benefits and possible risks involved will be documented in the patient's record. The Medical Director will review the information with female patients who become pregnant while in the program. The reveiw will be documented in the pateint's record. Timeframe for compliance is immediate and ongoing. Program Director will be responsible for oversight. |
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 the review of patient records and an interview with the Facility Director and the CRNP, the facility failed to ensure that the narcotic treatment physician determined the proper dosage level in one of fourteen patient records.
The findings include:
Twenty seven patient records were reviewed on February 1-3. 2011. Fourteen patient records were reviewed for the physician's documentation in determining the initial dose. One of fourteen patient records, specifically # 22, had a standing order documented for the initial dose.
Patient # 22 received an initial dose of 20 mg. Documented in patient record # 22 was an order by the physician that included a standing order to start patient at 20 mgs and increase to 35 mgs by Sunday, then re-evaluate. There was no documentation that the narcotic treatment physician continued to assess the patient to determine if an increase in the patient's dose was needed.
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Plan of Correction
The Medical Director will submit a new order for each increase or decrease of all patients, both new and current. "Standing Orders" will not be utilized for any new or current patient of Discovery House. This will be immediate and on-going. Program Director will monitor for compliance. |
715.16(b)(1-8) LICENSURE Take-home privileges
(b) The narcotic treatment physician shall consider the following in determining whether, in exercising reasonable clinical judgment, a patient is responsible in handling narcotic drugs:
(1) Absence of recent abuse of drugs (narcotic or non-narcotic), including alcohol.
(2) Regular narcotic treatment program attendance.
(3) Absence of serious behavioral problems at the narcotic treatment program.
(4) Absence of known recent criminal activity.
(5) Stability of the patient 's home environment and social relationships.
(6) Length of time in comprehensive maintenance treatment.
(7) Assurance that take-home medication can be safely stored within the patient 's home.
(8) Whether the rehabilitative benefit to the patient derived from decreasing the frequency of attendance outweighs the potential risks of drug diversion.
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Observations
Based on a review of patient records and staff interviews, the facility failed to consider the criteria for take-home privileges in two of twelve patient records.
The findings include:
Twenty seven patient records were reviewed on February 1-3, 2011. Twelve patient records were reviewed for compliance with the regulations regarding take-home medications. Per regulation, the narcotic treatment physician shall consider, utilizing the eight point criteria, take home privilege consideration. The facility failed to consider the criteria for take-home privileges in patient records # 4 and 25.
Patient # 4 was admitted into treatment on November 26, 2010. Patient # 4 transferred into treatment from another narcotic treatment program and was immediately granted take-home privileges. There was no documentation that the criteria had been considered for take-home privileges in patient record # 4.
Patient # 25 was admitted into treatment on July 13, 2010. Patient # 25 transferred into treatment from another narcotic treatment program and was immediately granted take home privileges. There was no documentation that the criteria had been considered for take home privileges in patient record # 25.
The facility director was interviewed on February 3, 2011. He reviewed patient records # 4 and 25 and confirmed that there was no documentation that the criteria had been considered prior to granting take-home privileges.
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Plan of Correction
A new 8-Point form will be filled out for each patient that transfers in from an outside agency other than another Discovery House. These transfers are considered to be "internal" transfers, therefore a new 8-point will not be necessary. This will be immediate and on-going. Clinical Supervisor will monitor for 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 observation of dosing, the facility failed to administer and dispense the medication in a manner that protected the patient from disruption or annoyance from other individuals.
The findings include:
Methadone monitoring was conducted February 1-3, 2011. Dosing was observed on February 2, 2011 from approximately 7:20 AM to 8:40 AM. It was observed that two separate patients at the window were engaging in conversation with someone other than the dispensing staff. Also, per agency policy, there are to be no hats, sunglasses, beverages or children at the dosing window. During dosing observation, six individuals presented at the dosing window while wearing hats. None of the six individuals were asked to remove their hat. These issues were not addressed by either the dispensing staff nor any other staff members.
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Plan of Correction
Only those patients who are dosing will be permitted to be within the dosing area. All other patients will be required to stand away from the area until they are called up by a dosing nurse. Our policy on no hats, sunglasses, beverages or children at the dosing window will also be strictly enforced. This will be immediate and on-going. Nurse Manager will monitor for 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 a review of patient records and staff interviews, the facility failed to 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.
The findings include:
Twenty seven patient records were reviewed on February 1-3, 2011. Eight patients were transferred into treatment from a narcotic treatment program. Per regulation, 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. The facility failed to 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 in record # 16.
Patient # 16 was transferred from a narcotic treatment program and admitted into treatment on November 18, 2010. There was no documentation that the facility notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient.
The clinical supervisor was interviewed on February 2, 2011 and confirmed the patient record did not contain documentation that they had 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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Plan of Correction
All transferring narcotic treatment programs will be notified of the admission of their patient to our program as well as the date of initial dose. This will be done in writing and documented in the transferring patient's chart. This will be immediate and on-going. Clinical Supervisor will monitor for compliance. |