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 24, 25 and 26, 2009 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 compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and a plan of correction is due on September 22, 2009.
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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 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 May, June and July were reviewed on August 24 and 25, 2009. There were insufficient onsite physician hours during May and July.
During the week of May 10 - May, 2009, the census was 437 patients and 28 physician hours
During the week of July 5 - July 11, 2009, the census was 447 patients and 40.99 physician hours.
During the week of July 19 - 25, 2009, the census was 447 patients and 42.04 physician hours.
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Plan of Correction
The Program Director will complete a monthly schedule for all medical staff to ensure compliance with medical hours. We have hired a CRNP as of 9/17/09 with a start date of 10/3/09. Program Director will monitor weekly to ensure hours are maintained. The program Director will update schedule as needed on a monthly basis. This will be completed by 10/3/09. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on the review of patient records, the facility failed to ensure the patient signed the informed consent prior to the administration of a narcotic agent in two of nine patient records.
The findings include:
Twenty five patient records were reviewed on August 24, 25 and 26, 2009. Informed consent documentation was required in nine patient records. The facility did not document patient informed consent prior to the administration of a narcotic agent in patient records # 2 and 24. Patient # 2 was admitted June 11, 2009; there was no signed consent to treat form in patient record # 2. Patient # 24 was admitted June 16, 2009; there was no signed consent to treat form in patient record # 24.
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Plan of Correction
Program Director will provide a training to Medical staff on intake procedures to include all documentation needed and time frames to complete as well as who's responsible. Charge Nurse will conduct an Initial quantitative Chart Review and sign off on the form to ensure all documents are signed before a patient is medicated. Program Director and Charge nurse will ensure compliance and this process will start by
10/5/09.
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715.14(c) LICENSURE Urine testing
(c) A narcotic treatment program shall develop and implement policies and procedures to minimize misidentification of urine specimens and to ensure that the tested specimens can be traced to the donor.
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Observations
Based on a review of policy and procedure the facility failed to provide policy and procedures that ensure accurate tracking of the urine specimen from collection to shipment to the laboratory to minimize misidentification and tracing the specimen back to the donor.
The finding include:
A review of the policy and procedure manual August 24, 25 and 26, 2009 revealed that the facility, upon patient request, will ensure that steps are taken to avoid misidentification. The regulations require this practice must be applied to all patients.
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Plan of Correction
Policy and Procedure will be changed to read that all patients will be provided accurate tracking of the urine specimen from collection to shipment to the laboratory to minimize misidentification and tracing the specimen back to the donor. Program Director will be responsible and it will take place within 30 days. |
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
Based upon review of patient records and the policy and procedure manual, the facility failed to document consideration of the eight point criteria for take-home privileges in one record.
The findings include:
Twenty five records were reviewed August 24, 25 and 26, 2009, twelve were reviewed for compliance with take-home privilege determination. Patient record # 4 contained documentation that identified that the patient had revealed during a session with her counselor that she had ongoing problems with her significant other. This information was not provided in the documentation that was presented to the physician for the patient to be considered for take-home privileges. Based on the information provided to the physician the patient received take-home privileges. In providing these privileges to patient #4 the facility failed to consider all eight points when they determined take-home privileges for this patient.
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Plan of Correction
Clinical supervisor will provide a training to clinical staff on the 8 point evaluation which will include documentation of all pertinent information relevant to the 8 points. Clinical Supervisor will also address this individually with clinical staff as needed to ensure compliance. This will take place within 30 days and Clinical Supervisor 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
Based on patient records, the facility failed to ensure the physician was the person determining patient doses in one of nine records.
The findings include:
Twenty five patient records were reviewed August 24, 25 and 26, 2009. Nine records were reviewed for dose determination content. The facility failed to provide documentation that only the physician was making dose determinations. Patient record # 4 contained a counselor note of June 3, 2009 that specified the counselor would submit a dose increase of 5 mg based on the patient's self reports. In the same patient record the clinical notes identified that the counselor responded to patient # 4's request for a dose increase by telling them they should wait a week before making a request to be seen by the physician.
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Plan of Correction
Clinical Supervisor will provide a training to clinical and medical staff on policy and procedures as it relates to 715.16(c)(1)(i-vi). Training will focus on patient requests for dose increases and procedures to follow as well as documenting this in patient records. This will take place within 30 days and Clinical supervisor will be responsible to ensure compliance via quarterly chart audits. |
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
Based on a review of patient records, the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment in 1 of 8 records.
The findings include:
Twenty five records were reviewed on August 24, 25 and 26, 2009, eight records were reviewed for psychotherapy content. The facility failed to ensure that patient # 4 received the required hours of psychotherapy. The patient entered treatment on April 16, 2009; documentation in the patient record revealed that patient #4 received 1 hour of therapy in May 2009, 2.5 hours in June 2009 and 2.5 hours in July 2009; these hours provided and average over the three month time of 2 hours a month.
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Plan of Correction
The Clinical Supervisor and Lead Counselor will conduct weekly reviews of Direct Service hours. Counselors with low clinical hours will be address during clinical supervision. Action plans will be completed with counselors who have low service hours. Clinical Service hours will also be run on a monthly basis to ensure counseling hours are met within time frames. Clinical Supervisor and lead counselor will be responsible and this has been put into action as of 9/18/09. |
715.21 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.
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Observations
Based on a review of facility policy and procedure, patient handbook and patient records the facility failed to provide documentation that involuntary terminations were initiated for only those reasons identified in the regulations.
The findings include:
The facility patient handbook specified that patients could be discharged for violation of program rules. Additional reasons for discharge included repeatedly missing appointments or rescheduling and discharge for failure to submit a urine sample.
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Plan of Correction
Program Director will remove language from the patient handbook until a revision of the handbook can be completed that indicates the potential termination for missing appointments, repeatedly rescheduling appointments, or not providing U/A samples. Program Director will be responsible and the removal of language will be completed 10/18/09 and revision will take place within 30 days. |
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 a review of patient records and policy and procedure, the facility failed to to document discharge summaries in two of four records.
The findings include:
Twenty five records were reviewed August 24 - 26, 2009, six were reviewed for patient discharge content. In patient record # 7, the facility failed to specify the reason for the patient's discharge. In patient record # 10, the facility did not include disposition regarding patient's transfer to another facility.
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Plan of Correction
Clinical Supervisor and lead counselor will provide a training to clinical staff on writing discharge summaries. This training will focus on documentation of reasons for discharge and documentation required for transfers. This training will take place within the net 30 days. Clinical Supervisor will monitor for compliance via a discharge audit to ensure all documentation is completed. |
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
Based on a review of patient records and facility policy and procedure, the facility failed to complete preliminary treatment plans at admission in two of six patient records.
The findings include:
Twenty five patient records were reviewed on August 24 -26, 2009, six were reviewed for preliminary treatment plan content. Preliminary treatment plans were to be completed at admission. Patient # 2 was admitted into treatment on 6/11/09; the preliminary treatment was completed on 6/24/09. Patient # 3 was admitted into treatment on 1/12/09; the plan was completed 1/22/09.
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Plan of Correction
A training will be provided by Clinical Supervisor to all clinical staff on writing initial treatment plans which will focus on outlining realistic short and long term treatment goals and time frames to be completed. Clinical Supervisor will review initial treatment plans before signing off on them and during individual supervision to monitor for compliance. This will be completed within 30 days. |
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 a review of patient records, the facility failed to document support services in patient treatment plans in eleven of eleven patient records.
the findings include:
Twenty five patient records were reviewed August 24 - 26, 2009, eleven were reviewed for treatment plan content. The facility failed to document support services for patients # 1, 2, 3, 4, 11, 12, 13, 14, 15, 16 and 25.
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Plan of Correction
A training will be provided by the clinical supervisor to clinical staff on identifying and documenting behavioral tasks a patient shall perform to complete each short term goal. Clinical Supervisor will monitor for compliance before approving and signing off on treatment plans. This will take place within 30 days |
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
Based on a review of patient records, staffing records, facility documentation and staff interview, the facility failed to maintain compliance with their Division approval for a caseload variance.
The findings include:
The facility requested and received approval to maintain caseloads of no more than fifty to one for qualified staff with caseloads that included patient with reduced psychotherapy requirements. The exception required that caseloads consist of more patients that required regular hours of pychotherapy than patients who had attained reduced counseling status. The facility failed to provide documentation that they were compliant with the exception as three counselors maintained a caseload that included more reduced caseload patients then those on a regular caseload.
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Plan of Correction
Clinical Supervisor and Program Director will review counselor caseload summaries on a quarterly basis to ensure compliance with the patient to counselor ratio stipulated in chapter 704.12(a)(6) and chapter 715.8(i)(vi). The initial review will take place on 9-30-09 and then quarterly thereafter. Program Director will be responsible to ensure compliance. |