INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on January 5, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site complaint investigation, Discovery House 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 a plan of correction is due on February 15, 2011.
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Plan of Correction
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715.14(a)(2) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
(2) If the narcotic treatment program determines that other drugs are abused in that narcotic treatment program 's locality or have been identified in the patient 's drug and alcohol history as being a drug of abuse or use, a narcotic treatment program may conduct a test or analysis for other drugs as well.
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Observations
Based on a review of patient records and an interview with the facility director, the facility failed to test for other drugs identified as abused by the patient in the the patient's drug and alcohol history in one of five patient records.
The findings include:
Seven patient records were reviewed on January 5, 2011, five were reviewed to determined compliance with this regulation. Patient # 3 reported continual use of marijuana at the time of their 2/24/10 admittance into treatment. This information was documented in the patient's drug and alcohol history. At the time of this investigation there was no drug screen urinalysis to determine continued use of marijuana.
This information was reviewed with the facility director and it was agreed that the patient should have been tested for marijuana.
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Plan of Correction
Program Director and Clinic Supervisor will provide training to all staff that if we determine that other drugs are abused in that narcotic treatment program's locality or have been identified in the patient 's drug and alcohol history as being a drug of abuse or use, we may conduct a test or analysis for other drugs as well. DHBC facility will test newly admitted patients for other drugs identified as abused by the patient in the patient's drug and alcohol history. Compliance will be monitored by the program director and/or clinical supervisor. Staff currently has been advised verbally and a comprehensive training will be conducted within 30 days. |
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
Based on the review of patient records and an interview with the clinical supervisor, the facility failed to ensure the physician documented in the patient record the rationale for granting take home medication in one of four patient records.
The findings include:
Seven patient records were reviewed on January 5, 2011. Four patient records were reviewed for take home medication documentation. Per regulation, the narcotic treatment physician shall document in the patient record the rationale for permitting take home medication. Patient record # 1 did not have the physician's rationale for granting the take home medication. The physician's documentation in the patient record stated that the patient had started a new job and was pregnant; there was no additional information in the record that specified the rationale for the physician to order take-home privileges for the patient.
In an interview with the facility director, it was confirmed there was no documentation of the physician rationale for granting take-home medication.
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Plan of Correction
Program Director and Clinic Supervisor will provide training to the Medical Director on documenting the physician's rationale for granting the take home medication. This will be monitored by the program director and/or the clinical supervisor. This staff has been advised verbally and a comprehensive training will be conducted 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 on a review of patient records and staff interviews, the facility failed to consider the criteria for take-home privileges in one of four patient records.
The findings include:
Seven patient records were reviewed on January 5, 2011. Four patient records were reviewed for compliance with the regulations regarding take-home medications. Per regulation, the narcotic treatment physician shall consider the following in exercising reasonable clinical judgment, a patient is responsible in handling narcotic drugs: absence of recent abuse of drugs (narcotic or non-narcotic), including alcohol, regular narcotic treatment program attendance, absence of serious behavioral problems at the narcotic treatment program, absence of known recent criminal activity, stability of the patient 's home environment and social relationships, length of time in comprehensive maintenance treatment. assurance that take-home medication can be safely stored within the patient 's home, and whether the rehabilitative benefit to the patient derived from decreasing the frequency of attendance outweighs the potential risks of drug diversion. The facility failed to consider the criteria for take-home privileges in patient record # 3.
Patient # 3 was admitted into treatment on February 24, 2010. At the time of this inspection, documentation in the patient record indicated the patient was receiving take-home privileges. A review of the patient record revealed a pattern of instability in their home environment that was not addressed or reviewed for consideration to rescind take-home privileges.
An interview with the facility director on January 5, 2011 confirmed that documentation in patient # 3's record revealed a pattern of instability that was not reviewed for consideration to rescind take-home privileges.
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Plan of Correction
Program Director and Clinic Supervisor will provide training to all staff on proper documentation and maintaining compliance in all areas of the 8 point when determining whether, in exercising reasonable clinical judgment, a patient is responsible in handling narcotic drugs. This process will be monitored by the program director and/or the clinical supervisor. Staff currently has been advised verbally and a comprehensive training will be conducted within 30 days. |
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 the review of patient records, the facility failed to demonstrate the physician made the determination of the patient's dose in two of four patient records.
The findings include:
Seven patient records were reviewed on January 3, 2011. Four patient records were reviewed for physician's documentation of the patient's initial and subsequent dose and schedule.
Patient # 1 was admitted June 2, 2010. A standard order was used to order the initial dose of 30 mg and then the increases of 5 mg "until stable" were left to the discretion of the nursing staff.
Patient # 9 was admitted June 23, 2010. A standard order was used to order the initial dose of 30 mg with "increases as needed to maintain stability" left to the discretion of the nursing staff.
On September 4, 2007, all narcotic treatment programs were issued a letter regarding the use of standard orders, especially during the induction phase, by the Department of Health & Human Services, Substance Abuse and Mental Health Services Administration: (SAMHSA)
In part, the following is excerpted from the letter:
"Because methadone overdose deaths have occurred in early treatment due to the drug's
cumulative effects of the first several days, it is also important to be cautious when
adjusting the dose. According to the drug labeling, the peak respiratory depressant
effects of methadone typically occur later and persist longer than its peak analgesic effects, which can contribute to cases of iatrogenic overdose, particularly during treatment initiation and dose titration. With repeated dosing, "methadone may be retained in the liver and released slowly, prolonging the duration of action despite low plasma concentrations." The drug labeling also states that "steady-state concentrations are not usually attained until 3 to 5 days of dosing," and that doses "will 'hold' for a
longer period of time as tissue stores of methadone accumulate." Therefore, patients should be closely monitored during the induction phase, and the increase in dose should be under the close supervision of a physician as stated in 42 CFR 8.12 (h)(4), ' Dosing and administration decisions shall be made by a program physician familiar with the most up-to-date product labeling'. "
An interview with the facility director on January 5, 2011, confirmed that standing orders had been issued in the treatment of patients # 1 and 9.
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Plan of Correction
The Medical Director will eliminate the use of standard orders, especially during the induction phase due to the dangers and need for close supervision from the physician. The Medical Director will maitain sole responsibility for orders made at induction. The program director will monitor for compliance and this change will be immediate and ongoing.
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