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 September 3 & 5, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center for Behavioral Health - PA, 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 October 7, 2008.
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Plan of Correction
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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 review of eight patient records, the facility failed to provide the physician's documentation of addiction prior to the administration of the methadone. This occurred in one of seven patient records where required.
Finding:
The facility did not document the current dependency or the one year history of addiction prior to patient #4 receiving the first dose of methadone. The patient was admitted on August 4, 2008, discharged on August 18, 2008, and the documentation of addiction was completed on August 15, 2008.
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Plan of Correction
Missing documentation brought to Medical Director's attention. Medical Director will complete documentation of addiction on every patient appropriate for treatment before an order is placed for patient to begin methadone maintenance. Program Manager will complete a clinical/medical chart audit to ensure documentation is in place. Program Director will oversee. |
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 eight patient records on September 4 and 5, 2008, the facility failed to provide documentation that the previous narcotic treatment program was contacted. This occurred in one of one patient record where required.
Finding:
The facility failed to provide documentation in patient record #3 that the previous narcotic treatment program was contacted.
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Plan of Correction
The person responsible for screening patient will ask for and if permiited, obtain a consent to release information from previous treatment facility. Consent to release will be sent to obtain specified information. Disclosure will be documented in patient's chart. Documentation of patient's refusal to consent to transfer of information will be made in patient intake note. Program manager will conduct clinical chart audit to ensure this task is completed. Program Director to oversee. |
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
Based on a review of eight patient records, the facility failed to provide an informed consent to release information form in four of the eight patient records where required.
Finding:
The facility failed to provide an informed consent to release information form in patient records # 1, 5, 6 and 7. Consent to releases information forms informed the client that information would be "obtained from" someone as well as "released to" someone. This construction does not support the requirement for an 'informed' consent to release information. In addition, patient record #1 included a facsimile form with another patients full name listed on the form..
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Plan of Correction
The computerized consent to release form will be changed in the updated version of software. In the meantime, Discovery House associates will begin to use a paper consent which does not contain the ability to "obtain" information, but only allow a facility to "release" information. Associates to complete training for paper consent during clinical meeting and begin using immediately. Clinical supervisor will review consents during supervison, Program Manager will complete clinical/medical chart audits, and Program Director will oversee.
Regular chart audits will be conducted in supervision by Clinical Supervisor to ensure filing mistakes no longer occur. |
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 seven patient records on September 4 and 5, 2008, the facility failed to document when the dose review was completed in one of two patient records where required.
Finding:
The facility failed to provide documentation of when the dose review was completed for patient record #8. Due to the date discrepancy, it could not be determined when the dose review was done. The first review is dated on the computer as 2-10-08, but the physician signature date is 3-20-08. The second review includes a computer date of 8-16-08, but the physician signature date is 8-19-08.
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Plan of Correction
This citation has been brought to the Medical Director's attention. The Medical Director will begin a note and finish it the same day to avoid confusion. Medical Director will complete dose reviews before date due. Program Director to monitor and oversee. |
715.20(4) 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.
(4) 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.
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Observations
Based on a review of seven patient records, the facility failed to provide documentation of the admission date and the date of the initial dose to the transferring facility in two of two patient records where required.
Finding:
The facility failed to provide documentation of the admission date and the date of the initial dose to the transferring facility in patient records # 5, and 7.
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Plan of Correction
The person responsible for screening patient for intake will complete the "Patient Transfer Acknowledgement" form. Once the patient begins medicating after a successful transfer, this form (which includes patient's admission date and date of initial dose) will be sent to previous narcotic treatment program and proof that the form had been sent will be kept in patient's file. Program Manager will conduct clinical/medical chart audit to ensure documentation was completed and sent. Program Director to oversee. |
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 a review of seven patient records on September 4 and 5, 2008, the facility failed to provide written notice of the involuntary termination in one of one patient record where required.
Finding:
The facility failed to provide written notice of involuntary termination in patient record #11.
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Plan of Correction
Training will be conducted with all Associates during next staff meeting to ensure that all patients who will undergo an involuntary termination is provided with written notice 24 hours before action to terminate is taken. Program Manager to monitor by conducting chart audits and Program Director to oversee. |
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
Based on a review of seven patient records, the facility failed to provide documentation of serology testing for two of seven records where required, and documentation of the mantoux testing in one of seven records where required.
Finding:
The facility failed to provide documentation of serology testing for patient records # 3 & 7, and documentation of the mantoux testing in patient record #5.
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Plan of Correction
This observation has been brought to the attention of Medical Director, CRNP, and Nurse Manager. All patients entering into treatment will have serology testing at the time of intake. Results will be filed in patient's chart. Mantoux testing will be offered/conducted immediately after admission. Results will be documented by medical Associate in compliance with regulation and policy. Program Manager will conduct clinical/medical chart audits for every new admission to monitor compliance. Program Director will oversee. |
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 seven patient records, the facility failed to provide a discharge summary in two of four records where required..
Finding:
The facility failed to provide a discharge summary in patient records # 10 and 11.
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Plan of Correction
This observation has been brought to the attention of the Clinical Associates. Counselors will complete discharge summary within one week after discharge. Clinical Supervisor will monitor using Service Due report and weekly supervision. Program Director to oversee. |
715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
Based on a review of the project's policy and procedures on September 3, 2008, the facility failed to provide a complete policy and procedure for reporting unusual incidents.
Finding:
The facility failed to include references to incidents # 1, 2, 4, 6 and 7 in the policy and procedure for reporting unusual incidents.
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Plan of Correction
This observation has been brought to the attention of Corporate Compliance and Policy. The policy and procedure has been changed to include all references for reporting unusual incidents and will be officially rolled out in 30 days. Program Manager will monitor to ensure all referenced unusual incidents are reported to the Department. |