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 December 4, 5, and 6, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House HA 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 corrections are due on January 7, 2008.
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Plan of Correction
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715.6(a)(3)(i) LICENSURE Physician staffing
(a) A narcotic treatment program shall designate a medical director to assume responsibility for administering all medical services performed by the narcotic treatment program.
(3) The medical director 's responsibilities include the following:
(i) Supervision of narcotic treatment physicians.
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Observations
The facility failed to provide documentation that the medical director's responsibilities include supervision of other narcotic treatment physicians.
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Plan of Correction
The Medical Director's job description will be amended to include supervision of other narcotic physicians. Director will be responsible. |
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 document that the prior narcotic treatment program was contacted and information was requested for patients # 15 and 18 whose drug and alcohol histories indicated both patients had prior narcotic addiction treatment.
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Plan of Correction
Releases will be placed in intake packet and be completed at intake and faxed for past narcotic TX records. Primary counselor will follow up with TX facility if not received in a timely manner. Clinical Supervisor will be responsible and will review during annual chart audits. |
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 to provide physician documentation of the assessment and need for continued methadone treatment within three months following patient # 20's termination of her pregnancy.
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Plan of Correction
Counselor will inform medical staff immediately when pregnancy is terminated so a meeting with the physician can be scheduled to evaluate the need for continued TX or detoxification. A training reviewing this regulation will be provided by director. Director will be responsible. |
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 and written consent to release information forms, it was determined that the facility failed to identify the recipient of the information and the entity's or person's relationship to the patient in records # 23 and 28. Additionally, it was observed during methadone dispensing that the nurse was drawing a black line randomly on the returned take home bottles; the black line should be drawn through the patient name in order to cross out the name to protect the patient's confidentiality.
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Plan of Correction
A training will be provided to all staff on how to complete a release of information, What information can be released, documenting the recipient of the information and the entity's or person's relationship to the patient.
A training will be provided to dispensing staff which will explain that all return takehome bottles will have all identifying features blacked out before discarding. Director will be responsible.
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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
Based on a review of clinic records, Certified Registered Nurse Practitioners (CRNP) conducted the annual physical examination for patients #22, 27, and 28. Documentation on the patient examination form completed by the CRNP reviewed the patient's dose and included the statement to continue current dose; only the physician may review and determine the patient's dose and schedule.
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Plan of Correction
A training will be provided for all CRNP's on their job responsibilities which will include that only physician's may review and determine the patients dose and dose schedule. Director will be responsible. |
715.16(b)(1-8) LICENSURE Take-home privileges
(b) The narcotic treatment physician shall consider the following in determining whether, in exercising reasonable clinical judgment, a patient is responsible in handling narcotic drugs:
(1) Absence of recent abuse of drugs (narcotic or non-narcotic), including alcohol.
(2) Regular narcotic treatment program attendance.
(3) Absence of serious behavioral problems at the narcotic treatment program.
(4) Absence of known recent criminal activity.
(5) Stability of the patient 's home environment and social relationships.
(6) Length of time in comprehensive maintenance treatment.
(7) Assurance that take-home medication can be safely stored within the patient 's home.
(8) Whether the rehabilitative benefit to the patient derived from decreasing the frequency of attendance outweighs the potential risks of drug diversion.
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Observations
The facility failed to consider the current illicit drug use of patients # 4 and 22 when the patient's eligibility to have and maintain take home bottles was determined. Facility policy states they will use the federal CSAT 8 point criteria as well as follow Department of Health regulations in determining if a patient is eligible for take home privileges.
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Plan of Correction
A training will be provided for all staff on the 8-point evaluation, state regulatory standards for takehomes, and documenting the rehabilitative benefit to the patient derived from decreasing the frequency of attendance to the clinic. Clinical Supervisor, Director, and Medical Director will be responsible for review of takehome requests 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
The facility failed to provide patients # 16 and 24 with the required minimum of 2.5 hours of psychotherapy each month.
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Plan of Correction
Clinical Supervisor will review weekly counseling hours provided and will utilize therapy before dosing when needed for non compliance with obtaining minimum counseling hours. Clinical Supervisor will also discuss deficiencies in counseling hours during clinical supervision to develop action plans for individual cases as needed. Director and Clinical Supervisor will be responsible. |
715.23(b)(11) LICENSURE Patient records
(b) Each patient file shall include the following information:
(11) Counselor notes regarding patient progress and status.
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Observations
A review of 32 patient records revealed a pattern of failure to document the clinical assessment and follow up to treatment issues. Specifically, patient # 11 informed his counselor of suicidal ideation; the clinical note referenced the concern on the specific date but there was no documentation of the clinical and medical efforts to address the patient's need nor was there any subsequent documentation that addressed the facility's follow up with patient.
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Plan of Correction
A training will be provided to all counselors on documentation of Patient records which will include follow up to treatment issues. Clinical Supervisor and Director will be responsible. |
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
Based on a review of client records, it was determined that the facility failed to ensure that the psychosocial evaluation contained a clinical analysis of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, client's attitude toward treatment and overall impressions. A review of seven of thirteen client records, specifically #2, 8, 10, 16, 18, 19 and 21, indicated that the psychosocial evaluation failed to document the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, client's attitude toward treatment and overall impressions based on the clinician's analysis of the collected historical information.
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Plan of Correction
A training will be provided for completing psychosocial evaluations and need to document clients problems, needs, assets, strengths, support systems, coping mechanisms, negative factors, clients attitude toward treatment, and overall impressions. Outside trainings will also be utilized for associates needing additional training. Clinical Supervisor and Director to monitor during clinical quality reviews to ensure compliance. |
715.23(b)(22) LICENSURE Patient records
(b) Each patient file shall include the following information:
(22) Aftercare plan, if applicable.
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Observations
The facility failed to provide aftercare plans that were specific to the needs of the patient at the time of their discharge. Based on chart review and staff interview, the plans are done at admission and contain generalized information. Patients # 1, 3, 4, 6, 7, 13 and 14 were discharged without benefit of an individualized aftercare plan.
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Plan of Correction
A training will be provided for all counselors on the completion of aftercare plans. Aftercare plans will be updated as a Patient is close to being discharged from treatment. Clinical Supervisor will review every aftercare that is completed each month to ensure that it is specific to the needs of the Patient and that proper referrals are being made for the Patient. |
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 provide documentation patient specific information in the discharge summaries for patients # 1, 3, 4, 5, 7, 8, 9, 13 and 14. The summaries contained generic, non-specific information that provided minimal information regarding reasons for treatment, progress and changes in patient life while in treatment and reasons for leaving treatment. Additionally, the facility failed to follow their policy to complete discharge summaries within one week of discharge; the discharge summaries for patients # 2, 7, and 11 were completed more than a week following their discharge.
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Plan of Correction
A training will be provided for all counselors on the purpose and process of completing discharge summaries. Clinical Supervisor will provide quality control to ensure that discharge summaries provide Patient specific information and are completed within 7 days of discharge. |
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
The facility failed to provide annual evaluations that addressed the required areas. Specifically, the patient chart review displayed evaluations that included one word answers or circled responses on the forms. An assessment of patients activity and progress was not included in the assessments.
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Plan of Correction
A training will be provided on writing annual evaluations which will address employment, education, training, legal standing, substance abuse, financial abilities, physical and emotional health, fulfillment of treatment objectives, and family and community support, and documenting this information. Clinical Supervisor will review during clinical quality review to ensure compliance. |
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
In a review of 13 patient records, the treatment plans consisted of a pattern of generic, non- specific treatment plans; the contents did not address the specific patient needs and goals.
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Plan of Correction
A in-service training will be provided on writing individualized treatment plans. Outside trainings will also be utilized for staff needing additional training. Training will address documentation of specific patient needs and goals. Clinical Supervisor to review Treatment plans before being posted as completed 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
The facility failed to develop treatment plans that contained short term goals with measurable steps. The treatment plans also failed to identify support systems needed by the patient. Of the thirteen patient charts reviewed, none contained measurable tasks to be completed by the patient to accomplish the short term goals.
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Plan of Correction
A in-service training will be provided on writing individualized treatment plans. Outside trainings will also be utilized for staff needing additional training. Training will address short and long term treatment goals and tasks a patient shall perform to complete each short term goal. Clinical Supervisor to review Treatment plans before being posted as completed to ensure compliance. |
715.29(5) 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.
(5) If the exception relates to a specific patient, the narcotic treatment program shall maintain documentation of the exception in the patient 's record.
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Observations
The facility failed to comply with the conditions of the exception granted by the Division regarding six day and thirteen day take-home privileges. Patients on six day and thirteen day status based on the exception must have quarterly call backs (an unscheduled return to the facility within 24 hours) that includes an inventory of patient's remaining take home supply,
drug testing or methadone plasma levels, and a review as to whether the reduced take-home schedule should continue. The facility failed to conduct quarterly call backs for patients # 21, 30 and 31.
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Plan of Correction
Policy on Call back regulations will be reviewed during a staff meeting and all staff will be provided with copy of the regulation. Clinical Supervisor and Director will review all exceptions on a monthly basis to ensure all call backs are completed in a appropriate time frame. Clinical Supervisor and Director will be responsible. |