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 and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on October 20 & 21, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House BC 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 November 18, 2009.
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Plan of Correction
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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 on a review of patient records, the facility failed to document the rationale for maintaining a patient on take-home privileges in one of four records.
The findings include:
Fifteen patient records were reviewed October 20 & 21, 2009, four were required to maintain documentation that pertained to take-home medication privileges. Patient record # 2 contained documentation that patient #2 had take-home privileges. A review of this patient record revealed documentation that the patient had not reported as scheduled for counseling appointments on 8/19, 9/2, 9/9 and 10/9; the reviewed documentation specified that patient was a "no show". Noncompliance with treatment program attendance is one of the eight point criteria utilized to determine the appropriateness for a patient to have take-home privileges.
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Plan of Correction
Program Director and Clinic Supervisor will provide training to all clinical and medical staff on the 8 points of the 8 point evaluation for takehomes. All documentation regarding rationale for takehomes will be reviewed during a clinical staff meeting attended by clinical supervisor, Medical Director, and Facility Director on a weekly basis to ensure compliance with the 8 points of the 8 point evaluation. Medical Director will sign off on all approved takehome requests. This process has started as of this date 11/16/09 and will be monitored by the program director. The training will be held within 30 days. |
715.17(b) LICENSURE Medication control
(b) A narcotic treatment program shall develop policies and procedures regarding verbal medication orders, including the issuing and receiving of orders, identifying circumstances when orders are appropriate and documenting orders, in accordance with applicable Federal and State statutes and regulations.
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Observations
Based on a review of patient records, policies and procedures and staff interview, the facility failed to document that verbal orders were signed within 24 hours of verbal issuance.
The findings include:
Fifteen patient records were reviewed October 20 & 21, 2009, twelve patient records were reviewed to
assess the timeliness of a physician's signature of a verbal order within 24 hours of verbal issuance.
The facility policy and procedure identified that verbal orders would be signed within 24 hours of issue.
Patient record #1 provided documentation that a verbal order was issued on 10/14/09 and signed by the physician on 10/28/09.
Patient record # 2 provided documentation that a verbal order was issued on 9/20 and signed by the physician on 9/25/09.
Patient record # 4 provided documentation that a verbal order was issued on 7/24 and signed by the physician on 7/27/09.
Patient record #5 provided documentation that a verbal order was issued on 10/10/09 and signed by the physician on 10/13/09.
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Plan of Correction
Program Director will provide a training to Medical Director and Nursing staff on Discovery House Policy and Procedure pertaining to verbal orders. Medical Director will review all verbal orders on a daily basis and sign within 24 hour time period. Program Director will monitor for compliance. Training will take place on 11/18/09. |
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
Based on the review of patient records, the narcotic treatment program failed to document all efforts to retain the patient in the program prior to initiating an involuntary termination in one of one patient records.
The findings include:
Fifteen patient records were reviewed on October 20 & 21, 2009. Documentation that an involuntary termination had been initiated was reviewed in one patient record. Facility documentation revealed that an involuntary termination was initiated with patient # 15 for financial noncompliance. Documentation in patient record # 15 identified a physician order which specified an involuntary taper of medications due to "financial hardship" and specified a taper of 9 mg per day. The patient was dosed at 85 mg on 7/16/09, 76 mg on 7/17/09, 67 mg on 7/18/09, and 58 mg on 7/19/09. Documentation in the patient record revealed resolution of the patient matter and he began an increase of 9 mg per day on 1/20/09. Involuntary termination for financial reasons is not an identified reason for a patient's involuntary termination.
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Plan of Correction
A training will be provided by program director to all Clinical and Medical staff on Involuntary terminations which will include reasons for termination, how to document reason, and documentation of efforts made to retain the patient. All future involuntary terminations will be signed off by the Program Director and Medical Director before an involuntary termination will begin. This process will begin as of today 11/17/2009 and the training will be completed within 30 days. Program Director will monitor for compliance. |
715.23(b)(13) LICENSURE Patient records
(b) Each patient file shall include the following information:
(13) Patient record of services.
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Observations
Based on a review of patient records, the facility failed to ensure the patient's record of services was complete and current in 3 of 9 patient records.
The findings include:
Fifteen records were reviewed on October 20 & 21, 2009, nine were reviewed for record of services. The record of services were not complete in three patient records:
Patient record # 1 did not include documentation of an individual counseling session that occurred on 9/22/09 and was documented in a progress note.
Patient record #5 contained a record of services that had not been updated since 8/01/09.
Patient record # 8 failed to include documentation of counseling sessions that occurred 8/26/09 and 10/14/09.
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Plan of Correction
Clinical Supervisor will provide training to all staff on a complete record of service. This will take place in the next 30 days. All Clinical staff will complete the record of service when services are provided. Clinical Supervisor to monitor during supervision and during chart audits 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
Based on the review of patient records, the narcotic treatment program failed to document treatment plans in fifteen of fifteen patient records.
The findings include:
Fifteen patient records were reviewed on October 20 &21, 2009. Treatment plans were required in fifteen patient records. The narcotic treatment program did not document support services in the treatment plan in patient records #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,12, 13 14 and 15.
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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 |