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 August 19, 20 & 21, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House CU was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on September 23, 2008.
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Plan of Correction
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715.14(b) LICENSURE Urine testing
(b) A narcotic treatment program shall develop and implement policies and procedures to ensure that urine collected from patients is unadulterated. These policies and procedures shall include random observation which shall be conducted professionally, ethically and in a manner which respects patient privacy.
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Observations
Based on a review of the policy and procedure manual and staff interviews from August 19, 2008 to August 21, 2008, the facility failed to maintain a urine drug screen policy that was consistent with their actual practice and regulation.
Findings:
Current policy and procedures failed to state that urine drug screens would be completed monthly for each patient.
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Plan of Correction
Policy will be reviewed and amended/changed/purged as needed. The Director and Policy Advisor from Discovery House home office will be responsible. |
715.15(f) LICENSURE Medication dosage
(f) The narcotic treatment program shall develop written policies and procedures relating to narcotic treatment medication dosage which includes the requirements of subsections (a)--(e).
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Observations
Based on a review of facility policy and procedures and staff interviews from August 19, 2008 to August 21, 2008, the facility failed to document a policy and procedure that included the actual practice utilized for take-home medications.
Findings:
The facility provided take-home bottles to patients that contained liquid medication, with each dose contained in a separate bottle. The current facility policy stated that the contents of the take-home bottles contained solid form medication and that six day take-homes could be stored in one container. The policy and procedure was inconsistent with the practice.
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Plan of Correction
Policy will be reviewed and amended/changed/purged as needed. The Director and Policy Advisor from Discovery House home office will be responsible. |
715.17(b) LICENSURE Medication control
(b) A narcotic treatment program shall develop policies and procedures regarding verbal medication orders, including the issuing and receiving of orders, identifying circumstances when orders are appropriate and documenting orders, in accordance with applicable Federal and State statutes and regulations.
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Observations
Based on a review of facility policy and procedures and 28 patient records on August 19 through August 21, 2008, 3 patient records were reviewed for compliance with verbal medication orders. The facility failed to comply with facility policy and state regulations in one of three patient records where required.
Findings:
Patient record #10 revealed that a verbal medication order was given on May 16, 2008 but was not signed by the physician until May 19, 2008. Verbal medications orders must be signed by the physician within 24 hours.
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Plan of Correction
The Program Director held an inservice with the medical director on 9/11/08 to ensure the medical director signs all verbal orders. The Program Director will over see to ensure compliance |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of 28 patient records, sixteen were reviewed for compliance with the requirements for the provision of psychotherapy services. The facility failed to provide each patient with the minimal requirement of an average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment. Psychotherapy was not provided as required in 2 of 16 patient records.
Findings:
Patient # 10 received 2.5 hours of psychotherapy in July 2008, 1 hour in June 2008, and 1 hour in May 2008 for an average of 1.5 hours of psychotherapy a month.
Patient # 11 received 1.45 hours of psychotherapy in July 2008, 2.5 hours in June 2008, and 2.5 hours in May 2008 for an average of 2.15 hours of psychotherapy a month.
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Plan of Correction
An inservice will be held by the Program Director and Clinical Supervisor to ensure that documentation will be provided to indicate whether a reduction in therapy is warranted. This will be monitored by the Clinical Supervisor and the Program Director will oversee to ensure compliance. |
715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of 28 patient records, 3 were reviewed for compliance with the standards for reduced psychotherapy hours following 2 years in treatment. The facility failed to provide individualized psychotherapy services in 3 of 3 patient records where required.
Findings:
The facility's computerized client records, the "Smart System", cues the counselor with a notice that the patient has completed two years of treatment and prompts the counselor to reduce the frequency of treatment. There was no documentation to indicate that the reduction in therapy was based on client need rather than time in treatment and the documentation that was in place was the same in three of three patient records. There was no documentation to support the reduction of psychotherapy services in patient records # 4, 14 and 19 and the documentation that was on file did not support the provision of individualized psychotherapy services in patient records # 4, 14 and 19.
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Plan of Correction
An inservice was held by the Clinical Supervisor and Program Director to ensure that documentation will be provided to indicate whether a reduction in therapy is warranted. This will be monitored by the CLinical Supervisor and the Program Director will oversee to ensure compliance. |
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 review of 28 patient records, 10 were reviewed for compliance with annual patient evaluations. The facility failed to ensure that all annual evaluations were completed as required in one of ten patient records.
Findings:
The physician signed the computerized statement attesting to the completion of the annual report in patient record # 1, but there was no documentation that the annual report had been completed.
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Plan of Correction
A training will be held by the Program Director to ensure that the Medical Director signs the correct computerized forms. An inservice will be held by the Clinical Supervisor to ensure that the annual reports are documented for each patient. The Clinical Supervisor will monitor compliance and the Program Director will oversee to ensure compliance. |
715.23(d)(1) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(1) The treatment plan shall identify the behavioral tasks a patient shall perform to complete each short-term goal.
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Observations
Based on a review of 28 patient records, 17 patient records were reviewed for treatment plan content. The facility failed to provide specific action steps with measurability and support services in 17 of 17 patient records where required.
Findings:
Seventeen patient records, specifically # 1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 13, 14, 15, 16, 18, and 20 contained vague, non-specific steps to reach their goals and the time frames were generalized rather than realistically specific to the action step. Further, the identified treatment plans did not include support services in any of the 17 records reviewed.
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Plan of Correction
An Inservice will be held by the Clinical Supervisor to ensure that each patient treatment plan contains specific steps in order for each patient to reach their goals and each plan will include support services. This will be monitored by the Clinical Supervisor when she approves treatment plans. The Program Director will monitor compliance. |