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 July 19-21, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, WPIC Narcotic Addiction Treatment Program 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.
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Plan of Correction
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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 and an interview with the Director of Narcotic Treatment Program Services, the facility failed to ensure that the narcotic treatment physician determined dose changes in accordance with the regulations and facility policy in five of eight patient records.
The findings include:
Twenty seven patient records were reviewed on July 19-21, 2011. Eight patient records were reviewed for the physician's documentation in determining the initial and subsequent dose of methadone. These records revealed that the physician was making determinations of incremental increases without direct assessment of the patient. The facility did not document that the narcotic treatment physician determined the proper dosage level in patient records #2, 8, 9,13 and 14.
Patient # 2 received an initial dose on June 9, 2011. Documented in patient record # 2 was an order by the physician dated June 13, 2011 that included a standing order to increase the patient dosage 5 mg daily for the next two days to 45 mg. There was no documentation that the narcotic treatment physician continued to assess the patient to determine if an increase in the patient's dose was needed.
Patient # 8 received an initial dose on September 1, 2011. Documented in patient record # 8 was an order by the physician dated September 1, 2010 that included a standing order to increase '5 mg x two days to 40 mg" commencing September 3, 2010. An order dated September 10, 2011 ordered a dose "increase of 5 mg every two days x four to 60 mg". There was no documentation that the narcotic treatment physician continued to assess the patient to determine if an increase in the patient's dose was needed.
Patient # 9 received an initial dose on October 27, 2011. Documented in patient record # 9 was an order by the physician dated November 1, 2011 that included a standing order to increase by "5 mg every two days x 3 to 145 mg". There was no documentation that the narcotic treatment physician continued to assess the patient to determine if an increase in the patient's dose was needed.
Documentation of a dose adjustment, signed by the nurse manager, stated to "decrease by 5 mg/week until 100 mg".
Patient #13 received an initial dose on February 4, 2011. Documented in patient record # 13 was an order by the physician dated February 4, 2011 that included a standing order stating, "methadone 90 mg PO daily effective today. Increase methadone 5 mg PO 2 days x 3 to 105 mg". A dose adjustment order dated February 14, 2011 included a standing order to "increase by 5 mg every 2 days x 3 to 120 mg, effective February 16, 2011". There was no documentation that the narcotic treatment physician continued to assess the patient to determine if an increase in the patient's dose was needed.
Patient # 14 received an initial dose on May 16, 2011. Documented in patient record # 14 was an order by the physician, dated May 16, 2011 that included a standing order stating, "methadone 75 mg PO daily, then increase to 80 mg PO daily for two days". An order dated June 7, 2011 stated to "increase methadone by 5 mg every 3 days to 90 mg and hold". There was no documentation that the narcotic treatment physician continued to assess the patient to determine if an increase in the patient's dose was needed.
An interview was conducted on June 20, 2011 @ approximately 12:30 P.M. with the facility director, medical director and clinical supervisor. No further documentation was provided.
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Plan of Correction
The Medical Director or her designee will communicate with all physicians by 8/15/11 that the initial and subsequent doses of methadone will require a written order each time there is a medication dose change. Each order shall be written, signed and dated by a physician.
The Medical Director will monitor compliance on a monthly basis.
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715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records and interviews with the facility director and clinical supervisor, the facility failed to document an average of 2.5 hours of psychotherapy per month during the patient's first two years, 1 hour of which shall be individual psychotherapy, in six of nine patient records, as required.
The findings include:
Twenty seven patient records were reviewed on June 19-21, 2011. Nine patient records were reviewed for the completion of an average of 2.5 psychotherapy hours per month. Per regulation, a narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient. The facility failed to document an average of 2.5 hours of psychotherapy per month in patient records # 10, 11, 12, 13, 14 and 15.
Patient # 10 was admitted on April 28, 2011. The patient received 0 hours of psychotherapy in May, 2011, 1/2 hour of psychotherapy in June, 2011. The patient received an average of .25 for the months of May and June, 2011.
Patient # 11 was admitted on December 9, 2010. The patient received 1 hour of psychotherapy in May, 2011, 1 hour of psychotherapy in June, 2011 and 2.5 hours of psychotherapy in July, 2011 . The patient received an average of 1.5 hours of psychotherapy for the months of May, June and July, 2011.
Patient #12 was admitted on October 8, 2009. The patient received 1 hour of psychotherapy in April, 2011, 0 hours of psychotherapy in May, 2011 and 2.5 hours of psychotherapy in June, 2011 . The patient received an average of 1.67 hours of psychotherapy for the months of April, May and June, 2011.
Patient #13 was admitted on February 4, 2011. The patient received 2.5 hours of psychotherapy in April, 2011, 2 hours of psychotherapy in May, 2011, of which only 1/2 hour was individual psychotherapy. The patient received 2.5 hours of psychotherapy in June, 2011, of which 0 hours were individual psychotherapy hours. The patient received an average of 1.83 hours of psychotherapy for the months of April, May and June, 2011. Patient received 1/2 hour of individual psychotherapy for the three month period.
Patient #14 was admitted on May 16, 2011. The patient's psychotherapy hours were reviewed for the three month period of May 16 to July 16, 2011. The patient received 2.5 hours of psychotherapy in May, 2011, 1 hour of psychotherapy in June, 2011, and 1.5 hours of psychotherapy in July, 2011. The patient received an average of 1.67 hours of psychotherapy for the three months of May, June and July, 2011.
Patient #15 was admitted on June 11, 2010. The patient received 2.5 hours of psychotherapy in April, 2011, 0 hours of psychotherapy in May, 2011 and 0 hours of psychotherapy in June, 2011 . The patient received an average of .83 hours of psychotherapy for the months of April, May and June, 2011.
The facility director and clinical supervisor were interviewed on July 21, 2011 @ approximately 3:00 P.M. No further documentation was provided.
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Plan of Correction
Program Director or his designee will meet with program staff in clinical staff meeting by 8/9/11 and review regulation requiring an average of 2.5 hours of therapy per month, 1 hour of which being individual therapy for first 2 years. Program Supervisor and Lead Therapist will use the weekly Therapy Compliance report to monitor adhearnace by each therapist. End of month therapy deficiency reports reviewed in individual supervision with therapists. Results will be reviewed with the Porgram Director on a monthly basis. |
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 the review of patient records and an interview with the clinical supervisor, the facility failed to document a discharge summary was completed within seven days, in four of eleven patient records.
The findings include:
Twenty seven patient records were reviewed on July 19-21, 2011. Eleven patient records were reviewed as discharged patient records. Eleven patient records reviewed required a discharge summary. Discharge summaries are to be completed within seven days of the patient's discharge. The facility did not document that a the discharge summary was completed within seven days in patient records # 20, 21, 22 and 25.
Patient # 20 was discharged on April 26, 2011. The discharge summary was to be completed by May 3, 2011. The discharge summary was completed on June 8, 2011.
Patient # 21 was discharged on April 27, 2011. The discharge summary was to be completed by May 4, 2011. The discharge summary was completed on June 10, 2011.
Patient # 22 was discharged on May 10, 2011. The discharge summary was to be completed by May 17, 2011. The discharge summary was completed on June 6, 2011.
Patient # 25 was discharged on June 13, 2011. The discharge summary was to be completed by June 20, 2011. The discharge summary was completed on June 30, 2011.
An interview with the clinical supervisor was conducted on June 21, 2011. No further documentation was provided.
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Plan of Correction
Program Director or his designee will monitor on a monthly basis the timely completion of discharge summaries as per regulations. Program Supervisor will print out and review patient discharge report from Methasoft and monitor 7 day window for completion of discharge summary on a weekly basis. Program Supervisor will provide re-training in clinical staff meeting by 8/9/11 re:adherance to completion of discharge summaries within 7 days. Program Supervisor will review results of monitoring with Program Director on a monthly basis. |