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 14-15, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center for Behavioral Health-HA, 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.
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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, the facility failed to provide narcotic treatment physician services at least one hour per week onsite for every ten patients, for five of the sixteen weeks reviewed.
The findings include:
The physician's and physician assistant's time sheets and weekly census reports for the months of January, February, March and April, 2014 were reviewed on May 14-15, 2014. The facility failed to provide a sufficient number of onsite physician hours during five of the sixteen weeks reviewed.
During the week ending February 7, 2014, the patient census was 458. The facility was required to have provided at least 46 physician hours. There were 35 physician hours documented.
During the week ending February 14, 2014, the patient census was 461. The facility was required to have provided at least 46 physician hours. There were 40.92 physician hours documented.
During the week ending February 21, 2014, the patient census was 460. The facility was required to have provided at least 40 physician hours. There were 33.23 physician hours documented.
During the week ending April 4, 2014, the patient census was 460. The facility was required to have provided at least 46 physician hours. There were 41 physician hours documented.
During the week ending April 25, 2014, the patient census was 460. The facility was required to have provided at least 46 physician hours. There were 41.90 physician hours documented.
The Facility Director was interviewed on May 15, 2014 and did not dispute the findings.
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Plan of Correction
The Program Director met with the Medical Director, Physician Assistant and Nurse Manager on May 16, 2014 to discuss the findings from the Methadone Monitoring on-site inspection that took place on May 14-15, 2014. In response to the citation, the Program Director and Clinical Supervisor will closely monitor the Physician's and Physician Assistants time sheets to insure the hours correlates with the clinics census in accordance to the state regulations. The Program Director will connect with other clinics within Discovery House to get assistance with maintaining compliance when the physician or physician assistant request time off. The Program Director will also work with the Physician and Physician Assistant in extending hours when necessary to insure compliance. The Program Director will also create a spreadsheet focused on the census and required hours by the Physician and Physician Assistant and will post it in the medical office. This will be monitored by the Program Director. |
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 the review of patient records, the facility failed to document that it notified the referring facility of the admission and initial dosing of the patient in 2 of 3 patient records.
The findings include:
Twenty patient records were reviewed on May 14-15, 2014. Three patient records were reviewed for documentation of notification to the referring facility of the admission and initial dosing of the referred patient. The facility failed to document that it notified the referring facility in patient records # 6 and 12.
Patient # 6 transferred from another narcotic treatment program and was admitted on April 14, 2014. There was no documentation that the transferring agency was notified of the patient's admission and initial dosing.
Patient # 12 transferred from another narcotic treatment program and was admitted on July 30, 2013. There was no documentation that the transferring agency was notified of the patient's admission and initial dosing.
The Facility Director and Clinical Supervisor were interviewed on May 15, 2014 and confirmed the findings.
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Plan of Correction
The Clinical Supervisors conducted a Clinical staff meeting on May 21, 2014 and instructed the Clinical team that whenever a patient transfers in from another clinic, a Transfer Acknowledgment form needs to be documented in the patients file in the computer and faxed to the transferring clinic. The form will be completed the day of admission. The Clinical Supervisors will insure that any information sent via fax is clear and in order prior to being scanned into the computer. This will be closely monitored by the First Key Process team and the Clinical Supervisors. |
715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
Based on the review of patient records, the facility failed to document the results of laboratory tests given by the narcotic treatment program in five of eleven patient records
The findings include:
Twenty patient records were reviewed on May 14-15, 2014. Eleven patient records were reviewed for documentation of the results of laboratory tests given by the narcotic treatment program. The facility failed to document the results of laboratory tests in patient records # 2, 7, 12, 15 and 17.
Patient # 2 was admitted on July 9, 2013. There was no documentation of Mantoux testing as of May 15, 2014.
Patient # 7 was admitted on December 23, 2013. There was no documentation of Mantoux testing as of May 15, 2014.
Patient # 12 was admitted on July 30, 2013. There was no documentation of Mantoux testing as of May 15, 2014.
Patient # 15 was admitted on October 3, 2013. There was no documentation of Mantoux testing as of May 15, 2014.
Patient # 17 was admitted on October 29, 2013. There was no documentation of Mantoux testing as of May 15, 2014.
The Facility Director was interviewed on May 15, 2014 and confirmed the findings.
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Plan of Correction
The Program Director met with the Physician Assistant and Nurse Manager to discuss the inspection findings. The Program Director instructed the Physician Assistant and Nurse Manager to meet with patients who were admitted when the Mantoux testing was unavailable due to a shortage and test those patients not tested upon intake. The Physician Assistant and Nurse Manager will insure that all information is documented appropriately in the patients file. This will be monitored by the Program Director. |