INITIAL COMMENTS
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This report is a result of an onsite licensure renewal and methadone monitoring inspection. The inspection was conducted on January 23-25, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite inspection, Discovery House was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during the inspection:
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Plan of Correction
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704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
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Observations
The facility failed to document a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served and that every effort will be made to hire staff persons representative of that population.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Recruitment and Hiring Policy will be updated by the Clinical Services Department, and Clinic Director will oversee this process. The policy will be updated by 1/15/2018. Every effort will be made to hire staff persons representative of the population served. Program Staff will continue to work with the Human Resource Business Partner in the recruitment and hiring of appropriate staff for the project. |
709.26 (a) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(1) Utilization of volunteers.
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Observations
The facility failed to have written project policies and procedures regarding the utilization of volunteers.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Personal Policy will be revised to include the utilization of volunteers in the project. Clinical Services Department will be responsible for updating the policy, and the Clinic Director will oversee this process. Policy will be updated by 1/15/2018. Clinic Director will review the policy revision with all staff in the February Staff Meeting.
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to document written policies and procedures regarding all of the client rights.
The policy and procedures manual and client handbook were reviewed. Neither the policy manual nor the client handbook documented 709.30 (4) Clients have the right to appeal a decision limiting access the their records to the director, (5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records, or
(6) Clients have the right to submit rebuttal data or memoranda to their own record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Services Department will update the Client Rights Policy and Procedure to include the client's right to appeal a decision limiting access to records to the director; clients having the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records; and clients having the right to submit rebuttal data or memoranda to their own record. Clinic Director will oversee this process, and will review the updated policy and procedure with all staff in the February Staff Meeting. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project.
Client #6 was admitted to treatment on 4/7/17 and involuntarily terminated from treatment on 7/20/17. There was not documentation that client #6 was provided with a written notification of involuntary termination.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A meeting will be held on 2/21/2018 for all staff to review the policy of administrative withdrawals. The steps that need to be followed and the forms that need to be completed will be reviewed. Every patient that is given an involuntary discharge will be given written documentation of the discharge. The Clinic Director and Clinical Supervisor will be responsible for insuring that the proper procedure is followed when a patient receives an administrative withdrawal |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
The facility failed to develop and policies and procedures to respond to the following unusual incidents:
709.34 (a)
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
(b) (5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State confidentiality laws.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Services Department will revise the Unusual Incident Policy and Procedure to include how the project will report and respond to a significant disruption of services due to disaster such as fire, storm, flood, or other occurrence which closes the facility for more than one day, including if the project requires the presence of police, fire, or ambulance personal on site.
Policy and Procedure will also be revised by the Clinical Services Department to ensure that the reporting of an unusual incident to an entity is in full compliance with State Confidentiality laws.
Policy revisions will be completed by the Clinical Services Department by 1/15/2018. Clinic Director will review these policy and procedure with all staff at the February 2018 Staff Meeting.
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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
The facility failed to document at least 1 hour of physician hours per week onsite for every ten patients.
The physician and physician assistant hours were reviewed on January 23-25, 2018. The physician assistant was not employed at the facilty for the period of October 1, 2017 to October 22, 2017. The physican hours and census for those weeks were as follows:
October 1-7, 2017 - 15 physician hours, 383 patients (38.3 physician hours required)
October 8-14, 2017 - 15 physician hours, 385 patients (38.5 physician hours required)
October 15-21, 2017 - 15 physician hours, 387 patients (38.7 physician hours required)
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The DH physician will provide the required on-site hours. The physician is responsible for providing 1/3 of the required hours and the Physician Assistant is responsible for providing the remaining 2/3 of the required hours. A meeting will be held on 2/20/2018 with the Medical Director to review the policy on physician staffing. The Clinic Director is responsible for monitoring and approving the hours spent on-site by the physician and physician assistant, this will be implemented immediately and monitored on an on-going basis. |
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 initial face to face determination of current physiological dependence and a 1 year history of dependence at the time of intake.
Buprenorphine patient records were reviewed on January 23-25, 2018. In patient record #13, the initial face to face assessment by the physician was reported to have occurred on 3/28/17; however, it was not signed by the physican until 10/27/17. In patient record #14, the initial face to face assessment by the physician was reported to have occurred on 10/3/17; however, it was not signed by the physican until 11/21/17.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A meeting will be held on 2/20/2018 with the Medical Director to review the policy on determining eligibility for admission into a narcotic treatment program. The DH physician shall document in the patient record the basis for the determination of current dependency and evidence of a 1 year history of addiction. The DH physician will sign the initial face to face assessment at the time of the patient visit. The Clinic Director will be responsible for monitoring the patient record to verify it was signed in a timely manner
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715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
The facility failed to ensure that each female patient was fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
Buprenorphine and methadone patient records were reviewed on January 23-25, 2018. Patient # 1, 4, 5, 7 and 13 were identified as female patients. No notification regarding the risks (as noted above) were provided to these patients.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the intake process for both methadone and buprenorphine the DH Intake staff will inform the female patients of the possible risks to her or her unborn child of illicit drugs and from use of or withdrawal from a narcotic drug administered or dispensed by the program. The DH intake counselor will have the patient sign the following form Pregnant Patient Acknowledgment of Risks a copy of which will be given to the patient. The Clinical Supervisor will be responsible for insuring that the proper procedure is followed when a female patient enters the program. Implementation will begin immediately and reviewed on an on-going basis |
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 physician determined the patient dosage level, but failed to document it at the time of the determination. The documentation is completed by the physician via the " Weekly medical follow up " notes.
Patient record #13 was reviewed on January 25, 2018. Patient #13 was admitted on 3/13/17. Eight " Weekly medical follow up " notes were signed six-seven months after the service occurred.
" Weekly medical follow up " appointments occurred with the physician on 4/4/17 & 4/18/17, but not signed by the physician until 10/27/17.
" Weekly medical follow up " appointment occurred with the physician on 5/16/17, but not signed by the physician until 11/21/17.
" Weekly medical follow up " appointments occurred with the physician on 5/23/17, 5/30/17, 6/6/17, 6/20/17 and 6/30/17 but not signed by the physician until 12/22/17.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A meeting will be held on 2/20/2018 with the Medical Director to review the policy on determining the proper dosage level for a patient. The DH physician will complete all dose reviews, the physician has been advised to sign dose reviews on the date of completion. The Clinic Director will monitor patient dose reviews on a daily basis to assure timely signing of patient records. Implementation will begin immediately and reviewed on an on-going basis
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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 failed to document that the patient met the criteria for 5 days of take home medication in patient record #2.
Methadone patient records were reviewed on January 23-25, 2018. Patient #2 was admitted as a transfer in on 10/6/17. On 10/27/17 an order was written that stated the patient was granted weekend privledges; however, due to an error, Monday through Friday take homes were checked. The patient was given 5 take home bottles for the weeks of 11/5/17 and 11/12/17 until the error was caught and changed back to weekend privledges.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A meeting was held on 2/19/2018 with the Clinical staff to review the regulations on take home privileges that all needed information is obtained and reviewed in the 8 point form prior to clinic action on take homes. The paperwork will contain information showing patient's satisfactory adherence to all applicable narcotic treatment program rules. The Clinical Supervisor will follow up to make sure the correct documentation is in the patient's chart prior to granting take homes. The Clinical Supervisor is responsible for training clinical staff and assuring accuracy of the 8 point form. The physician is responsible for reviewing and signing the 8 point and orders granting take homes. Implementation will begin immediately and reviewed on an on-going basis |
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
The facility failed to develop complete written transfer policies and procedures.
The policy and procedure manual was reviewed. The policies and procedures did not include that the facility would transfer the patient within 7 days of the request of the patient and 715.20(4).
709.20(4) states that 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.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Services Department will revise the Transfer Policy and Procedure to include that the project will transfer a patient within 7 days of the patent's request to be transferred. Clinic Director will review the policy and procedure revisions with all staff at the February 2018 Staff Meeting |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
The facilty failed to document that it transferred patient files for those patients that transferred to another narcotic treatment facility.
Patient records were reviewed on January 23-25, 2018. Two of the patients reviewed transferred to another narcotic treatment facility. Patient record #7 did not include documentation that the required patient information was transferred to the new narcotic treatment facility.
Patient #7 was admitted on 5/2/17 and transferred to another narcotic treatment facility on 8/2/17. There was no documentation in patient record #7 that patient information was transferred to the new narcotic treatment program, despite having a signed release of information in place.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical staff training will be provided on procedures for transfer of patients to other narcotic treatment facilities. This will include training on documentation of information released. Training will be performed by the clinical supervisor. The Clinical Supervisor is responsible compliance with the standard. Implementation will begin immediately and reviewed on an on-going basis
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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 develop policies which included 715.21 (1) (iv).
The policy and procedures manual was reviewed. The policy did not include that a patient may be involuntarily discharged if the patient has failed to follow treatment plan objectives.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Services Department will revise the Termination Policy and procedure to include that a patient may be involuntarily discharged from the project if the patient has failed to follow treatment plan objectives. Program Management will review these policy and procedure revisions with all staff at the February 2018 Staff Meeting.
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715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
The facility failed to document annual physicals in two of three patient records reviewed on January 23-25, 2018.
Patient #8 was admitted on 10/9/15. There was no annual physical and reevaluation documented for 2017 for patient #8.
Patient #10 was admitted on 11/1/03. There was no annual physical and reevaluation documented for 2017 for patient #10.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A meeting will be held on 2/20/2018 with the Medical Director to review the policy on patient records/annual physicals. The DH physician or PA is responsible for completing the patient's annual physical, the DH Physician will complete the annual physical exam including the full documentation of a re-evaluation on the patient on a timely basis. The Clinic Director is responsible for compliance with the standard. Implementation will begin immediately and reviewed on an on-going basis |