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 April 22, 23, and 24, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House, Inc 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 correction is due on May 27, 2008.
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Plan of Correction
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715.9(a)(3) 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:
(3) Obtain a drug use history and current drug use status of the individual.
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Observations
Based on a review of eighteen patient records, the facility failed to document a drug history and current drug use in one of eighteen records; specifically patient #20 intake information did not contain a drug history and current drug use that was obtained prior to the first dose of methadone being administered.
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Plan of Correction
All patients will have documented a complete drug history which includes current drug use. The Intake coordinator and medical director will review chart before admission to ensure completion before patient is admitted. Charts will also be reviewed during quarterly chart reviews. Director will be responsible on an ongoing and current basis. The form has already been developed and included in the intake packet as of 5/16/08. |
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
Based on a record review of 19 patient records, the physician's documentation is the same for each patient and does not account for individual patient differences. The physicians's documentation of intake form used to determine current dependency and a one year history of opioid dependence displayed a pattern of the same areas being marked for each patient. This occur in the 19 of 19 patient records.
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Plan of Correction
The medical Director will document current dependency and evidence of one year history of addiction for all potential admissions which shall be individualized. This will be documented in the initial physical examination. Director will monitor compliance via quarterly chart reviews and Corporate Medical Director will conduct a phone conference to train medical director. |
715.9(b)(2) LICENSURE Intake
(b) Exceptions to the requirements in subsection (a) are:
(2) Upon readmitting a patient who has been out of a narcotic treatment program for 6 months or less after a voluntary termination, the narcotic treatment program shall update the information in and review the patient 's file to show current opiate narcotic dependency, but need not conduct a physical examination and applicable laboratory tests. Privileges earned during the previous treatment may be reinstated at the discretion of the narcotic treatment physician.
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Observations
Based upon a review of records for patients who had been readmitted to treatment, the facility failed to update the patient record to show current opiate dependency in one of two patient records; specifically, patient # 9 was discharged from treatment on March 25, 2008 and was readmitted on April 7, 2008 without the physician's determination of current opiate dependency.
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Plan of Correction
A memo will be provided to medical staff stating that all re-admissions need to have updated documentation of current opiate dependence as well as updated patient record. Director will be responsible and perform quarterly chart audits for quality control |
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
Based on a review of nineteen patient records, the facility failed to, with patient consent, contact the previous narcotic treatment facility for the patient's prior treatment history in two of nineteen patient records. Specifically, patients # 21 and 37 had prior methadone treatment experiences; their patient records did not contain any documentation regarding their previous treatment experiences nor was there documentation that the information had been requested.
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Plan of Correction
A training will be held for staff on the regulations as it pertains to admissions that had prior treatment at another narcotic treatment program and the need to complete a release as well as obtain information about past treatment. Intake Coordinator will conduct chart audits to ensure compliance.
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715.10(c) LICENSURE Pregnant patients
(c) Counseling records and other appropriate patients records shall reflect the nature of prenatal support provided by the narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to ensure that pregnant patients' records reflected the nature of the prenatal support provided by the narcotic treatment program in two of four patient records, #1 and 24. Prenatal information in patient # 1's record was vague and did not include documentation of efforts and referrals to assist the patient to obtain prenatal care. Patient # 24 was pregnant when she was admitted to treatment but there is no documentation of her pregnancy in the physical examination nor did the initial treatment plan address her pregnancy and presenting needs..
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Plan of Correction
An in-service training will be provided by the clinical supervisor regarding appropriate documentation of pregnant patients as well as other high risk individuals which will include the addition of objectives in treatment plans and documentation of referral sources. In addition the Medical director will meet with all pregnant patients and document accordingly. Director Amy André McNamee will ensure the in service training will be provided.
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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 confidentiality with patient take-home bottles that were returned to the facility. Specifically, returned take-home bottles were observed to be thrown into the general trash containers the dispensing area. The empty bottles contained the patient's name and other identifying information related to packaged medication regulations required by Federal law. The facility failed to cross out the name of the patient. This practice failed to maintain the confidentiality of the patients with take-home privileges.
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Plan of Correction
A memo will be provided to dispensing staff informing them that all returned takehome bottles will have all identifiable information blacked out with a marker. Charge nurse will be responsible for follow through. |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on a review of 37 patient records, the facility failed to document that the physician reviewed the methadone dose levels for the patients at least twice a year. Specifically, the patient records reviewed contained documentation that the certified registered nurse practitioner had performed the dose reviews. Additionally, the facility's policy states that the semi-annual dose reviews were to be performed by the physician or "designee". Only the physician may perform the patient dose reviews.
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Plan of Correction
The medical Director will complete at minimum 2 annual dose reviews and document completion in the patient chart. Director and clinical supervisor will audit charts to ensure compliance. |
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 22 patient records, the facility failed to document that a consultation occurred between the physician and the certified registered nurse practitioner (CRNP) in five cases; specifically, patients # 22, 25, 26, 30, and 31 had the physical examination performed by the CRNP with no documentation of a consult with the physician prior to the physician's determination and order for the initial methadone dose.
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Plan of Correction
The medical director will be the only person to conduct the initial physical exams as well as determining the initial dose. If there was another narcotic treatment physician completing the initial physical a case consultation will be completed before a dose is determined. Director will ensure compliance by auditing all new admission charts. |
715.15(f) LICENSURE Medication dosage
(f) The narcotic treatment program shall develop written policies and procedures relating to narcotic treatment medication dosage which includes the requirements of subsections (a)--(e).
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Observations
The facility failed to document in their policy and procedures the specific responsibilities of the physician. The facility's policies included references to the "physician or designee" in making determinations regarding dose reviews. Only a physician can conduct a methadone dose review.
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Plan of Correction
Policy will be amended by the Corporate Office of Discovery House to ensure compliance as it relates to dose reviews and who can conduct them. |
715.16(a)(1) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(1) A narcotic treatment program may give take-home medications only to a patient who the narcotic treatment physician has determined is responsible and able to handle narcotic drugs outside the narcotic treatment program.
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Observations
Following a review of patient records, policy and procedure review, and staff interviews, the facility failed to comply with the policy and procedure to determine take-home privileges. In twenty three records reviewed, eleven patients (# 3, 4, 14, 21, 22, 25, 26, 30, 34, 35, and 37) received take-home privileges that were inconsistent with the policy and procedure.
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Plan of Correction
Director, Clinical Supervisor, and Medical Director will review all takehome requests to ensure their compliance with both state regulations as well as 8 points of the 8 point evaluation before the Medical Director gives final approval. The Director will ensure compliance via quarterly chart reviews. |
715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
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Observations
Of the 23 patient records that were reviewed, five applicable records were reviewed for take-home privileges. The facility failed to document that the physician made the determination for granting take-home privileges. Specifically, the physician referenced the decision for a patient to have take-home privileges as a "treatment" decision in four of the four records reviewed for content (patients # 21, 22, 26, and 29) with no further documentation in the patient record. Additionally, documentation reviewed in patient record # 29 contained counselor statements that take-homes privileges were approved by the counselor, not the physician as required.
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Plan of Correction
Director, Clinical Supervisor, and Medical Director will review all takehome requests to ensure their compliance with both state regulations as well as the 8 points of the 8 point evaluation before the Medical Director gives final approval. The Director will ensure compliance via quarterly chart reviews. |
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 the facility's policy and procedure regarding take-home privileges and the record review of 23 patient records for take-home privilege content, the facility failed to document that they addressed positive urinalysis results and other issues of potential concern in their review of patient # 14 's thirteen day take-home status.
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Plan of Correction
Director, Clinical Supervisor, and Medical Director will review all takehome requests to ensure their compliance with both state regulations as well as the 8 points of the 8 point evaluation before the Medical Director gives final approval. The Director will ensure compliance via quarterly chart reviews. |
715.17(c)(3)(i-v) 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:
(3) Inspection of storage areas. A narcotic treatment program shall inspect all drug storage areas and the dispensing station at least quarterly to ensure that the areas are maintained in compliance with Federal, State and local laws and regulations. A narcotic treatment program shall develop and implement written policies and procedures regarding who performs the inspections, how often, and in what manner the inspections are to be documented. The policies and procedures shall include the following:
(i) Disinfectants and drugs for external use shall be stored separately from oral and injectable drugs.
(ii) Drugs requiring special conditions for storage to insure stability shall be properly stored.
(iii) Outdated and contaminated drugs shall be removed and destroyed according to Federal and State regulations.
(iv) Administration of controlled substances shall be documented.
(v) Controlled substances and other abusable drugs shall be stored in accordance with Federal and State regulations.
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Observations
Based on facility policy and procedure which required monthly inspection of the drug storage area, and the review of facility documentation, the facility failed to complete inspections of the drug storage areas for the months of December 2007 and January 2008.
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Plan of Correction
Dispensing staff will conduct monthly inspections of the drug storage area. Director will ensure compliance via quarterly audits |
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
Following a review of policy and procedure, the facility failed to develop a transfer policy that provided patients with a clear and uncomplicated ability to have their cases transferred to a another narcotic treatment facility within seven days; specifically, the current policy and procedure indicated a transfer would occur unless it was medically determined not to transfer the patient or it was determined that the transfer was not in patient's best interests.
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Plan of Correction
Policy and procedure will be amended by the Corporate Office of Discovery House to ensure compliance state regulations as they pertain to patients requesting transfers to other facility. Clinical supervisor will monitor timely transfers of patients to designated faciities. |
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
Of the 23 patient records that were reviewed, the facility failed to document transfer information in three of eleven cases that were applicable. Specifically, documentation in patient # 5's record indicated a transfer took place but there was no information to identify the specifics of the transfer, including the name of the facility where the patient allegedly transferred; patient # 8's record contained documentation of a release to transfer to a facility, however, documentation indicated the patient was transferred to a different facility; and patient # 21's record contained no documentation of the information sent during the transfer process.
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Plan of Correction
Clinical supervisor will monitor any patient transfers and the necessary information and releases of information that need to be contained within transferring patient's chart. The clinical supervisor will also conduct and in-service addressing what information and releases of information must be included in any patient's chart wishing to transfer. |
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 restrict their policy and procedure on patient termination to the reasons permitted by regulation, specifically the facility involuntary terminated patients due to failure to maintain financial agreements. Of the 23 records reviewed, eighteen patient records were applicable for review of the termination content. Three patient records contained documentation of an administrative detoxification and termination for financial noncompliance. Patient # 12' s record indicated he was administratively discharged for noncompliance issues, including nonpayment, failure to maintain counseling hours, and continued use of illicit drugs; documentation in this patient's record failed to identify clinical efforts to support patient needs and to ensure all efforts had been initiated prior to the involuntary termination. Patient # 18 was placed on a 21 day administrative withdrawal (involuntary termination) for failure to maintain her financial agreement; documentation indicated she did make payment and the physician was advised he could restart her dose. Patient # 22 was placed on an involuntary detoxification for failure to maintain his financial agreement with the facility; documentation reviewed in the treatment plan update, dated January 9, 2008, identified that the patient was "...a financial detox at this time because he was not compliant with [the] objective of paying on time". Further review of the eighteen patient records indicated the patients were asked to sign forms that indicated that failure to maintain their financial agreement with the facility would result in administrative withdrawal or termination from treatment.
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Plan of Correction
An in service training will be conducted by facility Director to address involuntary termination and when they could be implemented. The training will include reasons for involuntary terminations, referral sources, as well as preventative measures to avoid terminations. It will also include the importance of documentation of this process. Director and clincal supervisor will monitor all patient cases that could result in involuntary termination to ensure all supportive clinical measures to support patient needs have been made. |
715.23(b)(3) LICENSURE Patient records
(b) Each patient file shall include the following information:
(3) A complete medical history
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Observations
Following a review of 23 patient records of which 18 records were reviewed for medical histories, the facility failed to document the patient's family medical history in three patient records, specifically, patients # 20, 25, and 33.
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Plan of Correction
A complete medical history will be documented in the patient chart. A new form will be added to current intake packet which will be completed by the counselor and reviewed by medical director. The Medical Director will also include Medical family history during his initial physical. Director will ensure compliance via quarterly audits. |
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
Following a review of 23 patient records, the facility failed to document actions taken that addressed the recommendations made for patient # 11's reported history of a prior positive tuberculosis Mantoux test.
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Plan of Correction
The medical director will ensure that all positive TB results will receive documentation and referrals regarding further treatment recommendations. Director will ensure compliance by conducting quarterly chart audits. |
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 23 patient records for patient record content, seven patient records, specifically #2, 10, 20, 25, 26 and 33, failed to document the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, patient's attitude toward treatment and overall clinical impressions.
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Plan of Correction
The clinical supervisor will conduct an in-service training to address staff on how to complete interpretive summaries, including identifying Strengths, Needs, Abilities, preferences, as well as clinical impressions and coping mechanisms. Clinical Supervisor will monitor via quarterly chart reviews. |
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
Based on a review of 23 patient records, 10 of which were reviewed for discharge content, the facility failed to develop a timely aftercare plan in one record; specifically, patient # 17 was discharged on January 22, 2008, but the aftercare plan was completed in September, 2007 during the annual patient evaluation. The aftercare plan did not address the patient's needs at the time of discharge.
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Plan of Correction
An in-service training will be provided by Clinical Supervisor on after care planning. The training will include when to update the aftercare plan and what content the plan should include. This inservice will take place on 5/30/08. |
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 23 patient records, the facility failed to document a complete discharge summary in six of ten closed records, specifically # 5, 6, 14, 16, 18, and 23. The summaries failed to document each patient's reason for seeking treatment and the patient's progress in treatment.
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Plan of Correction
An in-service training will be provided by Clinical Supervisor on aftercare planning on 5/30/08. The training will include when to update after care plan and what content the plan should include. |
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 the review of 23 patient records, the facility failed to develop treatment plans that contained short term goals with measurable steps in 8 records. The treatment plans failed to identify support services needed by the patient. Of the the 8 patient records reviewed, 7 patient records (# 2, 4, 6, 7, 12, 20 and 23) contained non-specific steps to reach the goals and the time frames were generalized rather than realistically specific to the action step. Three patient records (# 6, 12, 19) had no support services documented.
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Plan of Correction
An in-service training will be provided by the Clinical Supervisor on how to write treatment plans on 5/30/08. Counselors needing additional help will seek training from outside sources. The training will focus on short and long term measurable goals and support services needed by the patient. Clinical Supervisor will be responsible and ensure compliance by signing off on all treatment plans |
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
Based on a review of 23 patient records, the facility failed to document treatment plan updates based on the patient's progress as it relates to the goals stated in the comprehensive treatment plan in 13 records, specifically #1, 4, 10, 22, 24, 25, 26, 29, 30, 31, 33, 35 and 37. The treatment plan updates failed to address patient's progress in accomplishing the established goals. If new goals were added, no measurable interventions or action steps were developed.
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Plan of Correction
Clincial supervisor will provide an in-service training on how to write treatment plans. Counselors needing additional help will seek training from outside sources. The training will focus on documenting progress as it relates to the goals stated in the comprehensive treatment plan. Clinical supervisor will regularly review and approve treatment plans to ensure compliance. |