INITIAL COMMENTS
|
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 July 7-9, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center for Behavioral Health- HA, Inc was found not to be in compliance with the applicable chapters of 4 PA Code and 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on August 9, 2010.
|
Plan of Correction
|
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).
|
Observations
Based on the review of patient records and observation of the dosing area, the facility failed to maintain the confidentiality of all patient records.
The findings include:
Twenty one patient records were reviewed on July 7-9, 2010. Two patient records allowed for the release of information that exceeded the limitations imposed at 4 Pa. Code Subsection 255.5(b).
In patient records # 10 and 14, the consent to release information forms, signed by the patient, allowed for the release of drug test results to the medical assistance office. This exceeds the limitations on the release of information imposed at 4 Pa. Code Subsection 255.5(b).
Observation of the dosing area occurred on July 9, 2010 from approximately 9:00 AM to 9:30 AM. During the observation, the facility failed to maintain the confidentiality of patient records. Empty urine bottles were lined up on the inside of a dosing window that is not currently being used for dosing. The urine bottles had printed labels adhered to the bottle and this label was not visible to patients standing at the window. However, there was a second printed label, which included the patient's name, sitting face up on the empty urine bottles. A patient was at this window for several minutes and had access to the names on the patient labels.
An interview with the clinical supervisor and facility director on July 8 and 9, 2010 confirmed the release of information exceeded 709.28.
|
Plan of Correction
The clinical supervisor conducted an in-service training on July 15, 2010 with all associates regarding the releases for MA and VBH. Staff was reminded that MA and VBH releases can only contain the 5 point. Staff were instruced to go through their caseloads to determine who needs to be redone. The clinical supervisor and senior counselors will monitor charts through chart audits for compliance. The Nurse manager and program director met with nursing staff July 12, 2010 to inform them that urine labels could not be placed on top of specimen bottles to protect confidentiallity. The nurse manager will monitor the dispensary for compliance and the program director will do sporatic check in the dispensary to monitor compliance. |
715.13(a) LICENSURE Patient identification
(a) A narcotic treatment program shall use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
|
Observations
Based on observation of the dosing area and the policy and procedures manual, the facility failed to follow the facility's policy and procedures for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
The findings include:
The facility's dosing area was observed on July 9, 2010 from approximately 9:00 AM to 9:30 AM. The facility's policy and procedures for patient identification requires that the dispensing nurse will ask for the patient's number, name, amount of last dose and month and year of birth. During the observation, a dispensing nurse consistently stated the patient's identification number to the patient coming to the window and asked the patient if this was correct. The dispensing nurse did not ask the patients their name, last dose or month/year of birth.
|
Plan of Correction
On July 12, 2010 nursing staff had an inservice with the nurse manager and Program director going over the policy on the administration of medication. The Nurse Manager and Program Director went over the policy with them to ensure that proper identification is made before dispensing medication. The program director and nurse manager will be responsible to monitor compliance by observation in the dispensary during medicating hours. |
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.
|
Observations
Based on the review of patient records, the facility failed to ensure that the physician made the determination of the patient's subsequent dose in four of 21 patient records.
The findings include:
Twenty one patient records were reviewed on July 7-9, 2010. Patient records # 6, 9, 13 and 16 did not include documentation that the treatment physician had determined the patient's subsequent dose.
In patient record # 6, a nurse's note, dated June 1, 2010, stated that the patient required an increase and that the patient was to increase 5 mgs from 70 to 75 mgs. The physician's order documented in the record for this increase was dated June 2, 2010.
Patient records # 9, 10 and 13 contained documentation by the physician assistant to increase the patient's dosage.
In patient record # 9, there were four physician assistant notes which increased the patient's dose. The note dated May 4, 2010 stated patient to increase 10 mgs to 35 mgs and adjust PRN. Follow up in one week or sooner if necessary. The note dated May 11, 2010 stated patient to increase 10 mgs to 40 mgs and adjust PRN. The note dated May 18, 2010 stated the patient was to have a dose increase to 45 mgs. The note dated May 25, 2010 stated the patient was to have a dose increase to 50 mgs.
In patient record # 10, there were three physician assistant notes which increased the patient's dose. The note dated March 2, 2010 stated the patient was to have a dose increase to 40 mgs and adjust PRN. The note dated March 16, 2010 stated the patient was to resume dose for 4 days and increase 10 mgs to 60 mgs. The note dated March 23, 2010 stated patient to have a dose increase from 15 mgs to 65 mgs.
In patient record 13, there were four physician assistant notes which increased the patient's dose. The note dated March 23, 2010 stated the patient was to have a dose increase of 5 mgs to 25 mgs. The note dated March 31, 2010 stated the patient was to have a dose increase of 5 mgs to 30 mgs. The note dated April 8 2010 stated the patient was to have a dose increase of 5 mgs to 40 mgs and adjust PRN. The note dated April 14, 2010 stated the patient was to have a dose increase of 5 mgs to 45 mgs.
This is a repeat citation.
|
Plan of Correction
The Program Director held an inservice on July 12, 2010 with the Physician Assistant and nursing staff explaining the proper documentation of dosage increase and decrease reminded that only the medical director can determine dose increases or decreases. Notes will be documented as a consultation with the Medical Director making the final determination of dosage. The program director will do sporadic checks to monitor compliance. |
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.
|
Observations
Based on a review of patient records, the narcotic treatment program failed to document what materials were sent to the receiving narcotic treatment program in one of two patient records.
The findings include:
Twenty one patient records were reviewed on July 7-9, 2010. Two records required documentation of the materials sent to the receiving provider for the patient's transfer. In patient record # 16, there was no documentation in the patient record of the materials sent to the receiving narcotic treatment program.
An interview with the clinical supervisor on July 9, 2010, confirmed that there was no documentation provided that the materials were sent to the receiving narcotic treatment program.
This is a repeat citation.
|
Plan of Correction
The clinical supervisor held and inservie on July 15, 2010 to inform staff of proper documentation need when a patient transfers to another facility. Staff informed that transfer paperwork needs to be filed with the fax transmittal form and filed in patients chart whenever a patient transfers to another facility. The staff was also instructed to complete a General Note stating that the paperwork was faxed. The will be monitored by the clinical supervisor and senior counselor through chart audits for compliance. |
715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
|
Observations
Based on the review of patient records and an interview with the clinical supervisor, the facility failed to document that physical examinations were completed before each patient received their initial dose of methadone in two of ten patient records.
The findings included:
Twenty one patient records were reviewed on July 7-9, 2010. Ten patient records were due for documentation of the completion of the initial intake physical examination prior to the patient's initial dose of methadone. In patient records # 16 and 21, the physician's signature on the physical examination post dated the initial date of dosing .
Patient #16, admitted October 15, 2010 was initially dosed on October 15, 2010. The documented completion of the physical exam completed by the physician was dated October 16, 2010
Patient # 21, admitted October 26, 2010 was initially dosed on October 26, 2010. The documented completion of the physical exam completed by the physician was dated October 27, 2010
The facility director was interviewed on July 8 and 9, 2010 and she stated that the physician always completes the physical prior to the initial dosing on a hard copy of the physical examination form and signs and dates this form prior to dosing. The information is then entered into the computer. The facility director was not able to provide documentation of the hard copy physical examination forms during the inspection.
|
Plan of Correction
The program director held and inservice with the physician assistant on July 12, 2010 explaining that all initial physicals need to be documented on the the day of admission and if it can not be entered into the electronic chart that day the hard copy signed by the medical director the day of admission will be filed the the patient chart. The program director will do sporadic checks on new admissions to monitor compliance. |
715.29(4) LICENSURE Exceptions
A narcotic treatment program is permitted, at the time of application or any time thereafter, to request an exception from a specific regulation.
(4) The narcotic treatment program shall maintain documentation of the Department 's approval of an exception.
|
Observations
Based on observation of the dosing area and the policy and procedures manual, the facility failed to follow the requirements of an exception granted by the Division of Drug and Alcohol Program Licensing.
The findings include:
An exception dated November 6, 2006 permitted oral swabs to be used for drug screening urinalysis for patients with medical problems that precluded their ability to void urine on demand. The facility's dosing area was observed on July 9, 2010 from approximately 9:00 AM to 9:30 AM. During the observation of the dosing area, a patient stated that he was unable to provide a urine sample. The patient was then given an oral swab test.
During an interview with the facility director, clinical supervisor and the nurse manager on July 9, 2010, it was confirmed that the facility did not have medical documentation that the patient had a medical problem that precluded their ability to void urine on demand. The nurse manager stated that the patient has medical problems that preclude the patient from voiding urine on demand, but the patient has not provided medical documentation to the facility.
|
Plan of Correction
The Program Director and Nurse Manager met with nursing staff on July 12, 2010 to go over the exception on oral swabs. Nurses were informed that oral swabs can only be done on patient with medical documentation in their file stating they can not void urine and need to be swabbed. The program director and nurse manager will be monitor the specimens for compliance. |
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.
|
Observations
Based on the review of patient records and an interview with the facility director, the facility failed to document that the patient was provided written notification of the decision to involuntarily terminate the patient's treatment at the project.
The findings include:
Twenty one patient records were reviewed on July 7-9, 2010. Two patient records included documentation of an involuntary patient termination. Project staff failed to notify the patients, in writing, of a decision to terminate their treatment at the project. The facility did not document that the patient received written notice of the project's decision to terminate the patient's treatment in patient records # 17 and 18.
Patient # 17 was admitted on October 31, 2008 and involuntarily terminated on November 12, 2009. There was no documentation the patient had received written notice of the involuntary termination of treatment services.
Patient # 18 was admitted on July 22, 2008 and involuntarily terminated on November 3, 2009. There was no documentation the patient had received written notice of the involuntary termination of treatment services.
During an interview on July 9, 2010, the facility director confirmed that there was no documentation provided that the patients had received written notice of the involuntary termination of treatment services.
|
Plan of Correction
Clinical supervisor held an inservice training on July 15, 2010 with all staff in regards to involuntary discharges. Staff was informed that any patients who are involuntarily discharged must be given written notification of reason for discharge prior to their discharge. If the patient leaves the premisis before they can be given this form with reasons for discharge it will be mailed to their home. The program director will monitor involuntary discharges for compliance. |