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 October 14-16, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House, Inc. 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 November 20, 2008.
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Plan of Correction
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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 the review of the facilities policy and procedure manual on October 14, 2008 and October 16, 2008, the facility failed to restrict the reviewing the dosage levels to the physician only in their policy and procedure .
Findings:
The policy and procedure manual contained language allowing the physician to assign a designee to review patient dosage levels.
This was a repeat deficiency from the last methadone monitoring review.
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Plan of Correction
The policy will be amended by the Corporate Office of Discovery House to ensure compliance as it relates to dose reviews and who can conduct them. |
715.17(c)(7) 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:
(7) Drug reactions and medication errors. A narcotic treatment program shall report any adverse drug reaction or medication error to a narcotic treatment physician immediately and initiate corrective action. The narcotic treatment program shall record the reaction or error in the drug administration record and the clinical chart, and shall inform each person who is authorized to administer medication or supervise self-medication of the reaction or error.
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Observations
Based on the review of administrative documentation on October 15, 2008, the facility facility failed to notify the narcotic treatment physician immediately of a methadone medication error in September 2008.
Findings:
An incident report documented in September 2008 contained details that the patient advocate located in Rhode Island was immediately notified rather than the physician on duty. There was no documentation the physician was ever notified.
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Plan of Correction
The director will conduct a in-service training for staff members on the policy of notifying the medical director immediately of any medication errors. Steps on how to proceed if a patient recognizes that an error was made in their dose, and reports it to a staff person will be addressed. Also, if nursing recognizes that a dosing error was made, they have been instructed to immediately call the medical director to report the error and have patient see the doctor if at all possible. The director will conduct monthly reviews of all incident reports to ensure that this policy is being followed for all medication errors, as well as having all staff notify the director of all medication errors after notifying the medical director when an error occurs. |
715.20 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.
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Observations
Based on the review of the policy and procedure manual on October 14, 2008, the facility failed to develop a transfer policy that provided patients with a clear and uncomplicated ability to have their treatment transferred to another facility within 7 days.
Findings:
The policy and procedure manual continued to contain documentation that the transfer would be initiated unless it was medically determined not to be in the patient's best interest, that the patient would then have to leave against medical advice) AMA. The regulation does not allow for this stipulation to be included.
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Plan of Correction
The policy will be amended by the Corporate Office of Discovery House to ensure compliance as it relates to providing patients with a clear and uncomplicated ability to have their treatment transferred to another facility within 7 days. |
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 the policy and procedure manual on October 14, 2008 and patient records on October 15-16, 2008, the facility failed to restrict their policy and procedure on patient termination to the reasons permitted by regulation.
Findings:
The policy and procedure manual contained language that patients may be terminated if presenting as danger to him/herself and in examples of immediate discharge revealing a weapon of any kind.
Record # 20 contained documentation under alerts for the payment plan that stated "a medically supervised withdraw (MSW) was posted" and the physician followed up with an order to discharge due to patient's non-compliance.
Record # 21 contained documentation in the discharge summary that patient was being discharged for failure to follow financial obligations/refusal to pay. There was no documentation in the progress notes or treatment plan to support any effort by the facility to direct patient financially except a treatment plan objective that the patient would remain financially compliant and the counselor would monitor monthly.
Record # 22 contained documentation under alerts for the payment plan that stated "a medically supervised withdraw (MSW) was posted" and the physician followed up with an order to discharge due to patient's non-compliance. In addition, the discharge documentation stated patient had trouble keeping up with his account.
Record # 23 contained documentation under alerts for the payment plan that stated "a medically supervised withdraw (MSW) was posted" and "payment due today" after which the physician followed up with an order to discharge due to patient's non-compliance. There was no documentation in the progress notes or treatment plan to support any effort by the facility to direct patient financially except a treatment plan objective that the patient would remain active on medical assistance.
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Plan of Correction
An in service training will be conducted by facility Director to address involuntary termination and when they could be implemented. The training will include reasons for involuntary terminations, referral sources, as well as preventative measures to avoid terminations. It will also include the importance of documentation of this process. Director and clinical supervisor will monitor all patient cases that could result in involuntary termination to ensure all supportive clinical measures to support patient needs have been made. |
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 the review of 26 patient records on October 15 and 16, 2008, four records were reviewed for treatment plan compliance and three of four failed to identify the behavioral tasks the patients were to perform to complete each short-term goal.
Findings:
Record # 2 identified cocaine use as a problem statement but there were no documented behavioral tasks identified for the patient to work on to stop using cocaine. Instead, there were interventions documented that the counselor would do.
Record # 17 listed recovery as a short term goal, but there were no identified behavioral tasks identified for the patient to complete to meet the goal. Instead, there were interventions documented that the counselor would do.
Record # 18 contained a short term goal addressing relapse, but there were no identified behavioral tasks identified for the patient to complete to meet the goal. Instead, there were interventions documented that the counselor would do.
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Plan of Correction
An in-service training will be provided by the Clinical Supervisor on how to write treatment plans by 11/30/08. Counselors needing additional help will seek training from outside sources. The training will focus on short and long term measurable goals and support services needed by the patient. Clinical Supervisor will be responsible and ensure compliance by signing off on all treatment plans. |
715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
Based on the review of the policy and procedure manual on October 14, 2008 and October 16, 2008, the facility failed to have a complete policy and procedure for unusual incidents.
Findings:
The policy and procedure manual contained a statement that they would respond to unusual incidents. There was no identification of what the facility identified as an unusual incident, nor were there any procedures to address the specific nine unusual incidents listed in the standards. Therefore, there was no way to determine what steps the facility would take to respond to specific incidents.
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Plan of Correction
The policy will be amended by the Corporate Office of Discovery House to ensure compliance as it relates to defining unusual incidents, and listing procedures to address the specific nine unusual incidents listed in the standards. |