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 November 7-8, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Habit OPCO, 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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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of administrative documentation and discussion with administrative staff, the facility failed to document at least one hour of physician time a week, on site, for every ten patients.
The findings include:
Physician time sheets and and census reports for the months of July, August, September and October 2012, were reviewed on November 7, 2012. There were insufficient onsite physician hours during July, August and October. No physician hours were available for review for the month of September.
During the week of July 17 and 19, 2012, 5 physician hours were documented. During the week of July 26, 2012, 3.5 physician hours were documented. The facility provided the average monthly census for July 2012 as 77 patients.
During the week of August 2, 2012, 5.5 physician hours were documented. During the week of August 9, 2012, 6 physician hours were documented. During the week of August 16, 2012, 6 physician hours were documented. During the week of August 23, 2012, 5 physician hours were documented. During the week of August 30, 2012, 7 physician hours were documented. The facility provided the average monthly census for August 2012 as 85 patients.
The facility provided the average monthly census for September 2012 as 89 patients. However, no documentation of physician hours for the month of September was presented for review.
During the week of October 4, 2012, 4.5 physician hours were documented. During the week of October 11, 2012, 6 physician hours were documented. During the week of October 18, 2012, 4 physician hours were documented. During the week of October 25, 2012, 4 physician hours were documented. The facility provided the average monthly census for October 2012 as 92 patients.
The findings were discussed with the facility director and the findings were not disputed.
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Plan of Correction
THe facility had been attempting to negotiate an increase in the physicians hours with a third party. Subsequent to the audit, on November 13, 2012, the physician signed an employment agreement directly with the facility and will be providing a minimum of 6 additional hours per week. This contract sllows us to directly negotiate additional hours with the physician. This will ensure that the physician will be on site for 1 hour for every 10 patients on the active census. Additionally, the Nurse Manager has begun (effective 11/1) to track physician hours by maintaining an on site calendar to present to future auditors. This will eliminate a reliance on physician invoices as proof of physician time worked. The Nurse manager will maintain the calendar, and the Facility Director will monitor ongoing compliance by reviewing completed calendars on a monthly basis. Ongoing. |
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 in three of five patient records.
The findings include:
Thirteen patient records were reviewed November 7-8, 2012. Five records were reviewed specifically for consents to release information documentation.
Patient record # 1 contained consents to various funding sources and a government agency that listed all information from the patient's record to be released.
Patient record # 4 contained a consent to release information that listed the discharge summary and patient's dose information to be released to the funding source.
Patient record # 11 contained a consent to release information allowing the release of the psychosocial evaluation to the funding source.
The findings were discussed with the facility director and the findings were not disputed.
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Plan of Correction
Staff members will be provided training on Confidentiality (specifically, 42 CFR Part 2 and 4 PA Code 255.5) at a regular monthly staff meeting (November 16, 2012).
Additionally, the EHR generated consent forms have been modified (effective November 9, 2012) so that the options on the Consent form "checklists" for are now limited to the five (5) areas allowed under 255.5. If staff members need to send any information that exceeds the info that can be released under the most stringent standard (255.5), or if the facility needs to request information from a prior treatment provider (which would exceed 255.5), the specific items to be released AND the rationale for such a release are required to be documented on the consent form in the text boxes. The facility director and/or lead clinciain will monitor this for ongoing compliance via random monthly chart reviews. Ongoing. |
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 the review of patient records, the facility failed to ensure the physician dated the signature after submitting a verbal order in four of four patient records reviewed.
The findings include:
Thirteen patient records were reviewed November 7-8, 2012. Four records were reviewed for documentation of a physician's verbal orders. While the physician did sign these verbal orders, the signature was dated more then 24 hours after the order was given in. In addition, one of the patient records, # 11, also contained documentation of a verbal order being given by one physician and signed by another physician.
Patient record # 4 contained documentation of a verbal order given by the physician on August 21, 2012 and not signed until August 23, 2012.
Patient record # 8 contained multiple verbal orders. A verbal order on October 7, 2012 was not signed until October 9, 2012. A verbal order on October 10, 2012 was not signed until October 16, 2012. A verbal order on November 1, 2012 was not signed until November 8, 2012.
Patient record # 11 contained documentation of verbal orders being written and not signed within 24 hours as required by regulation. A verbal order was issued on September 13, 2012 by one physician and signed by another physician on September 15, 2012. A verbal order issued on October 4, 2012 was not signed until October 9, 2012.
Patient record # 12 contained documentation of verbal orders being written and not signed within 24 hours as required by regulation. A verbal order issued on September 25, 2012 was not signed until September 28, 2012. A verbal order was issued on October 4, 2012 and not signed until October 9, 2012.
The findings were discussed with the facility director and the findings were not disputed.
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Plan of Correction
The Physician will be provided remote access to the VNC Server via software and/or the distribution of a mobile computing device. The Physician has been notified that there is an expectation that the verbal orders are signed within 24 hours. She acknowledged a verbal understanding of same. The physician will have the software by 11/16/2012. Use of this software and compliance with the requirement will be monitored by the Facility Director and the Nurse Manager via random monthly chart audits. ONGOING |
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 handbook and the policy and procedure manual, the facility failed to restrict their policy and procedure on involuntary terminations to those areas specified in the regulations.
The findings include:
A review of the patient handbook on November 7, 2012 revealed that patients were informed they could be terminated for reasons other that those specified by regulations. According to the handbook documentation, patients could be terminated for reasons such as loitering, illicit drug use, funding/insurance issues and nonpayment for treatment services.
A review of the policy manual on November 7, 2012 revealed patients could be terminated for suspicious behaviors, falsifying urine drug screens, loitering, repeated non-compliance of safe parking laws, repeated failure to comply with the no visitor rule, failure to pay, and an immediate discharge without provision for detoxification when a physician "reasonably" determines continuous treatment presents serious risk.
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Plan of Correction
The Policies and Procedures for Pennsylvania programs are scheduled to be rewritten in December 2012. The handbook is scheduled to be rewritten and provided to patients in the month of January 2013. In the meanwhile, patients will be provided with a document that indicates the specific reasons for discharge as indicated in policy. The document will be placed at the dosing window and patients will be asked to sign the document (as proof of their awareness of same). Additionally, a label which contains the reasons for discharge, as indicated in regulations, will be placed in the handbook to ensure admissions are notfied of this information prior to the printing of the new handbook. The facility director will be responsible for ensuring that the handout and labels are generated. The facility director will also be responsible for ensuring that the new handbook is deisseminated after completion. Staff members will be provided with a copy of the new handbook at a staff meeting atleast 14 days prior to distribution to patients. The purpose of the staff meeting is to in-service staff on programmatic changes. The Facility Director will provide the training. Ongoing compliance with enforcement of the new handbook will be accomplished via random monthly chart reviews by the facility director and/or the lead clincian. Ongoing. |
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 facility failed to complete discharge summaries as required in two of three patient records reviewed.
The findings include:
Thirteen patient records were reviewed November 7-8, 2012. Three patient records required a completed discharge summary within a week of discharge.
Patient # 11 was admitted August 6, 2012 and discharged October 25, 2012. There was no discharge summary completed as of November 8, 2012.
Patient # 13 was admitted May 31, 2012 and discharged October 31, 2012. There was no discharge summary completed as of November 8, 2012.
In addition, patient # 6 was discharged November 4, 2012 and while a discharge summary was completed, it failed to include the reason patient entered treatment.
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Plan of Correction
Clincians will be trained on the policy related to discharge summaries, and the timely completion of same, at the November 16, 2012 general staff meeting. All clinicians will be provided with a copy of the pertinent regulations/standards. Ongoing compliance will be monitored via random monthly chart reviews by the facility director and the lead clinician. Ongoing. |