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 7, 2007 to August 9, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center For Behavioral Health-Pa, 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 and a plan of correction is due on August 30, 2007.
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Plan of Correction
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715.6(b)(1-9) LICENSURE Physician Staffing
(b) A narcotic treatment program may employ narcotic treatment physicians to assist the medical director. A narcotic treatment physician 's responsibilities include:
(1) Performing a medical history and physical exam.
(2) Determining diagnosis and determining narcotic dependence.
(3) Reviewing treatment plans.
(4) Determining dosage and all changes in doses.
(5) Ordering take-home privileges.
(6) Discussing cases with the treatment team.
(7) Issuing verbal orders pertaining to patient care.
(8) Assessing coexisting medical and psychiatric disorders.
(9) Treating or making appropriate referrals for treatment of these disorders.
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Observations
The facility failed to include the determination of narcotic dependence as one of the responsibilities of the narcotic treatment physician.
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Plan of Correction
Job description will be rewritten to ensure compliance. Director will be responsible. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
The facility failed to document the determination for current dependency in one of fifteen patients records reviewed, specifically patient record #12 whose admission urine drug screen was negative for all substances tested for, including opiates and methadone.
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Plan of Correction
Upon review, it was found that this patient was admitted in 2006, before the letter from the PA Department of Health in 2007 requiring UA result before medication is administered. Discovery House Butler will continue admitting patients only after a positive UA result for opiates in compliance with letter received from the Department. Program Director will oversee. |
715.9(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
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Observations
The facility failed to contact the previous narcotic treatment facilities identified in one of one patient records reviewed, patient record # 3. The patient record did not indicate that the patient refused to allow the facility to contact the prior treatment facility.
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Plan of Correction
Clinical Supervisor will provide supervision on how to properly document patient's refusal for consent to release. Clinical supervisor will ensure that all previous treatment facilities are contacted as per consent to release. Program Director will monitor. |
715.10(d) LICENSURE Pregnant patients
(d) Within 3 months after termination of pregnancy, the narcotic treatment physician shall enter an evaluation of the patient 's treatment status into her record and state whether she should remain in comprehensive maintenance treatment or receive detoxification treatment.
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Observations
The facility failed in one of one patient records reviewed, patient record # 1, to evaluate the treatment status within 90 days after termination of the pregnancy to determine whether comprehensive maintenance treatment or detoxification services should be provided.
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Plan of Correction
Training of medical associates responsible will be conducted and documented in supervision as needed. Medical Director will monitor compliance. Program Director will oversee. |
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
The facility failed to maintain the confidentiality of patient identity by having another patient's documentation in the patient records of patient records # 1 and # 2. There was documentation in patient records # 12 and # 24 demonstrating that patient specific disclosures of information through written letters and phone calls to third persons, without having obtained the written consent of the patient, were made by facility staff. In addition, there were consents to release information in patient records # 18 and # 20 that were not specific regarding the information that would be released.
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Plan of Correction
Clinical Supervisor will conduct and in-service training on confidentiality and appropriate release completion. Clinical Supervisor will monitor compliance through chart reviews. Program Director will oversee. |
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
The facility failed to ensure the medication dosing orders were complete. In particular, the written orders observed in seventeen of seventeen records reviewed, #1, 2, 4, 5, 6, 7, 8, 10, 12, 13, 14, 17, 21, 22, 23, 24, and 25, only indicated physician documentation of the patient's request and did not include the physician's dose order or dosing schedule change. In addition, patient record # 24 had documentation of the physician extender determining the continuation of a dose without with the physician making the dose determination and writing the order. Also, in patient record # 24, a counselor changed the patient's requested dose decrease instead of requested the doctor make that determination.
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Plan of Correction
The Medical Director will be advised in writing of the deficiencies. Physician extenders and counselors will immediately be advised of the limitations of their roles. Program Manager will monitor compliance through medical chart reviews. Program Director will oversee. |
715.16(a)(5) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(5) A narcotic treatment program shall develop written policies and procedures relating to granting and rescinding take-home medication privileges.
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Observations
The facility included a procedure allowing the treatment team to determine and recommend take home privileges of patients to the narcotic treatment program physician. Only the narcotic treatment physician may determine take home doses.
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Plan of Correction
This policy has been amended to allow only Medical Director to determine take home doses. |
715.16(c)(2)(i-iv) LICENSURE Take-home previliges
(c) A narcotic treatment program shall require a patient to come to the narcotic treatment program for observation daily or at least 6 days a week for comprehensive maintenance treatment, unless a patient is permitted to receive take-home medication as follows:
(2) A narcotic treatment program may permit a patient to reduce attendance at the narcotic treatment program for observation to two times weekly and receive no more than a 3-day take-home supply of medication when in the reasonable clinical judgment of the narcotic treatment physician, which is documented in the patient record:
(i) A patient demonstrates satisfactory adherence to narcotic treatment program rules for at least 2 years.
(ii) A patient demonstrates substantial progress in rehabilitation.
(iii) A patient demonstrates responsibility in handling narcotic drugs.
(iv) A patient demonstrates that rehabilitation progress would improve by decreasing the frequency of attendance for observation.
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Observations
The facility permitted patient # 17 to receive take-home medication despite the patient's self-reporting of continued use of an illegal substance, as evidenced in the patient record through progress notes and treatment plan goals.
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Plan of Correction
Clinical Supervisor will conduct an in service training on patient criteria for take home status. Medical Director will order or deny the request. Program Director will oversee. |
715.16(c)(3)(i-viii) LICENSURE Take-home privileges
(c) A narcotic treatment program shall require a patient to come to the narcotic treatment program for observation daily or at least 6 days a week for comprehensive maintenance treatment, unless a patient is permitted to receive take-home medication as follows:
(3) A narcotic treatment program may permit a patient to reduce attendance at the narcotic treatment program for observation to one time weekly and receive no more than a 6-day take-home supply of medication when in the reasonable clinical judgment of the narcotic treatment physician, which is documented in the patient record:
(i) A patient demonstrates satisfactory adherence to narcotic treatment program rules for at least 3 years.
(ii) A patient demonstrates substantial progress in rehabilitation.
(iii) A patient demonstrates responsibility in handling narcotic drugs.
(iv) A patient demonstrates that rehabilitation progress would improve by decreasing the frequency of attendance for observation.
(v) A patient demonstrates no major behavioral problems.
(vi) A patient is employed, is actively seeking employment, attends school, is a homemaker or is considered unemployable for mental or physical reasons.
(vii) A patient is not known to have abused alcohol or other drugs within the previous year.
(viii) A patient is not known to have engaged in any criminal activity within the previous year.
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Observations
The facility failed to follow the regulations regarding take-home privileges and permitted patient # 13 six day take-home privileges despite documentation indicating the patient was not employed, had abused alcohol and spent time in jail for DUI.
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Plan of Correction
Clinical Supervisor will conduct an in service training on patient criteria for take home status. Medical Director will order or recind take home status. Program Director will oversee. |
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
The facility failed to include procedures for the issuance of verbal orders, specifically what circumstances would warrant issuing of a verbal order.
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Plan of Correction
Policies will be reviewed and amended. Program Director will be responsible. |
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
The facility failed to ensure patient # 11 was observed ingesting the methadone dose as she was able to keep the medication dose inside her mouth until she reached the parking lot and then transferred the medication dose that was in her mouth to her friend's mouth.
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Plan of Correction
This issue was addressed immediately with dispensing associates and training was completed. Nurse Manager will monitor that all patients swallow medication before leaving dispensing window. Program Director will oversee. |
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
The facility failed to provide the minimum hours of psychotherapy for three of six patient records reviewed, # 1, 24, and 25. In addition, the treatment focus for all records reviewed was completing the minimum therapy hours and not based on the needs of the individual patient.
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Plan of Correction
Clinical Supervisor will run the Direct Services Report for each counselor during weekly supervision. Counseling requirements will be addressed and documented in individual supervision as needed. Program Director will oversee. |
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
The facility failed to ensure patients #14 and #15, two of two patient records reviewed, received additional psychotherapy despite documentation assessing the need for more than the minimum required therapy hours. Patient #14 expressed suicidal thoughts and was having a difficult time dealing with the holiday season. This patient had no individual counseling in October and November 2006. Patient #15 was in an abusive relationship and related drug cravings. The counseling for this patient also remained at 1 hour of counseling per month.
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Plan of Correction
Clinical Supervisor will conduct an in service training on at risk patients and clinical considerations for determining appropriate services. Clinical supervisor will follow up by addressing and documenting individual issues in supervision as needed. Clinical supervisor will review patients who are on a reduced counseling schedule in weekly supervison to ensure compliance. Program Director will oversee. |
715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
The facility failed to ensure in two of two patient records reviewed, that patients #13 and #16 received additional psychotherapy despite documentation that assessed the need for more than the minimum required therapy hours. Patient #13 received one-half hour of individual counseling in May, June, and July, 2007 despite continued alcohol use that included being arrested for a DUI. Patient # 16 also received one-half hour of therapy every month but reported ongoing drug cravings.
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Plan of Correction
Clinical Supervisor will conduct an in service training on at risk patients and clinical considerations for determining appropriate services. Clinical Supervisor will follow up by addressing and documenting individual issues in supervision as needed. Clinical supervisor will review patients with reduced counseling in weekly supervision to ensure compliance. Program Director will oversee. |
715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
The facility failed to document the information that was sent to the receiving facility in one of one patient records reviewed, # 27.
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Plan of Correction
Clinical Supervisor will conduct an in service training on properly documenting disclosure. Clinical Supervisor will monitor compliance through chart reviews. Program Director will oversee. |
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
The facility failed to notify the transferring narcotic treatment program of the admission and the date of the initial dose given to the patient in five of five patient records reviewed, # 2, 10, 17, 24, and 25.
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Plan of Correction
Nursing department will be trained on how to properly document confirmation of dose and notification of transferring patient. Nurse manager to monitor records for compliance. Program Director to oversee. |
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
The facility failed to comply with the allowable reasons, as stated in the regulations, for the involuntary termination of a patient from methadone, a life sustaining medication. Specifically the policy and procedures required an immediate discharge for any patient who had a weapon on the facility premise. This is not an allowable reason for an involuntary discharge.
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Plan of Correction
Policies will be reviewed and amended. Director will be responsible. |
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
The facility failed to ensure required laboratory results were included in three of thirteen patient records reviewed, patient # 1 and patient # 25 were missing documentation of a tuberculosis Mantoux test and patient # 22 was missing a blood serology report.
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Plan of Correction
Program Manager will complete clinical/medical chart audits to ensure medical information is properly obtained. Nurse Practitioner will monitor compliance. Program Director will oversee. |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
The facility failed to develop an evaluative assessment of the historical data obtained. Rather, the facility addressed the six dimensions required for American Society of Addictive Medicine (ASAM) admission criteria. These dimensions failed to provide a comprehensive evaluation of the patient. Statements read, "patient reported" or "patient denied" with no evaluation. This occurred in fifteen of fifteen patient records reviewed, # 1, 2, 3, 4, 9, 10, 11, 12, 17, 21, 22, 23, 24, 25, 26, and 27.
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Plan of Correction
Clinical Supervisor will conduct an in service training on the assessment process. Clinical Supervisor will monitor compliance through chart reviews. Follow up will be addressed and documented in individual supervision as needed. Program Director to oversee. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
The facility failed to include the reasons for entering treatment and a summary of the response to treatment in five of five discharged patient records reviewed, # 3, 11, 12, 20, and 27.
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Plan of Correction
Clinical supervisor will conduct an in service training on completing discharge summaries. Clinical Supervisor will monitor compliance through chart reviews. Program Director will oversee. This training has already been conducted on above date. |
715.23(d) 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.
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Observations
The facility failed to prepare an individualized treatment plan outlining realistic treatment goals based on the specific needs of the patient. Instead, the facility developed a generic treatment plan for records reviewed, in particular, four of five records included #1, 2, 17, and 24 failed to have an individualized treatment plan developed. Patient # 25 failed to have a comprehensive treatment plan developed within the 30 day timeframe required by the facility.
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Plan of Correction
Clinical Supervisor will conduct an in service training on realistic treatment goals. Follow up will be addressed and documented in individual supervision as needed. Associate responsible for completing initial treatment plans will monitor compliance and timely completion through chart reviews. Program Director will oversee. |
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
The facility failed to identify behavioral tasks for the patients to complete to meet the goal statement, but rather had generalized objectives for the patient to achieve in four of four patient records reviewed, #1, 2, 17, and 24. The fifth patient recorded reviewed for treatment plan content, patient # 25, did not have a treatment plan.
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Plan of Correction
Clinical Supervisor will conduct an in service training on behavioral tasks and objectives. Clinical supervisor will monitor compliance through chart reviews, and ensure timely completion. Program Director will oversee. |
715.23(d)(2) 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.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
The facility failed to ensure the treatment plan updates reviewed had documentation showing the goals were reviewed, re-evaluated, modified when indicated and the progress the patient made in achieving the prior goals. Instead, there were statements addressing the six American Society for Addiction Medicine (ASAM) dimensions used for determining level of care. This was found in five of six patient records reviewed for updates, in particular patient records #1, 2, 17, 23, and 24. In addition, a treatment plan update was missing in patient record # 18.
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Plan of Correction
Clinical Supervisor will conduct an in service training on the appropriate documentation for treatment plan reviews. Clinical supervisor will monitor compliance through chart reviews. Program Director will oversee. |
715.26(b) LICENSURE Security
(b) Each narcotic treatment program shall provide the Department with a specific plan describing the efforts it will make to avoid disruption of the community by its patients and the actions it will take to assure responsiveness to the community. This plan shall designate a staff member to act as community liaison.
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Observations
The facility failed to develop a site specific plan that addressed the actions that the facility would undertake to assure responsiveness to the community. This plan needed to address who was responsible, what was to be done, and the frequency of the actions.
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Plan of Correction
Program Director will develop a revised Community Action Plan to meet all facets of regulations. Program Director responsible. |
715.29(4) LICENSURE Exceptions
A narcotic treatment program is permitted, at the time of application or any time thereafter, to request an exception from a specific regulation.
(4) The narcotic treatment program shall maintain documentation of the Department 's approval of an exception.
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Observations
The facility failed to comply with the specific conditions set forth in the exception that was granted to permit a higher client to counselor ratio. The conditions for the Narcotic Treatment Program (NTP) are:
1. The NTP must have a full license and approval;
2. Qualified counselors must have been employed with the NTP for minimally one year;
3. Counselor assistants may not be included in this variance;
4. No more than one half of a caseload may include patients on a reduced schedule; the maximum caseload may not exceed 50.
5. The NTP must have a tracking system that allows efficient identification; at any time, of the caseloads specifying those on a reduced schedule and those not on a reduced schedule.
6. The NTP must utilize Department approved criteria in determining patients appropriate for a medical caseload.
The facility failed to comply with #4. Counselor H exceeded the allowable maximum caseload by one patient. The facility also failed to comply with #5 as patients were placed on a reduced counseling session as soon they completed either 2 or 4 years of treatment. The patient's need for treatment based on the patient's presenting problems was not considered in determining the reduced counseling session.
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Plan of Correction
This counselor's caseload has already been changed and brought into compliance with regulation. In service training on at risk patients will address service reduction considerations. Clinical supervisor will review the "direct services report" for tracking and individual caseloads weekly to ensure continued compliance. Program Director will oversee. |