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 August 2-4, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House 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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715.9(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 the review of clinical documentation, the facility, particularly the physician, failed to accurately document the basis for determining current and one year history of dependency in three of four patient records.
The findings include:
Twenty one patient records were reviewed August 2-4, 2011. Four patient records were reviewed for physician documentation of the basis for determining current dependency and evidence of one year history of addiction.
Patient # 2 was admitted March 17, 2011. The only documentation by the physician for evidence of at least one year history of addiction was the patient statement to the physician.
Patient # 19 was admitted July 1, 2011. The only documentation by the physician for evidence of at least one year history of addiction was the patient statement to the physician.
Patient # 20 was admitted March 17, 2011. The only documentation by the physician for determination of current dependency and evidence of at least one year history of addiction was that the patient had needle tracks. There was no indication of whether these needle tracks were fresh marks or scar tissue.
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Plan of Correction
Program Director and Clinic Supervisor will provide training to the Medical Director on providing a detailed rationale and documentation by the physician for determination of current dependency and evidence of at least one year history of addiction. This documentation will provide a clear basis on what factors were involved in the physician's determination of current dependency and supporting evidence of at least one year history of addiction. This will occur during the face to face meeting between the physician and the patient. 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. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on the review of patient records, the facility failed to complete the annual physical with a re-evaluation by the physician in five of six patient records reviewed.
The findings include:
Twenty one patient records were reviewed August 2-4, 2011. Six patient records required an annual history and physical that included an annual re-evaluation by the narcotic treatment physician.
Patient # 5 was admitted January 13, 2010. The annual physical exam was completed on January 10, 2011 by the narcotic treatment physician, but it did not include a re-evaluation.
Patient # 6 was admitted December 16, 2009. The annual physical exam was completed on December 22, 2010 by the narcotic treatment physician, but it did not include a re-evaluation.
Patient # 9 was admitted June 18, 2010. The annual physical exam was completed on June 15, 2011 by the Certified Physician Assistant (PAc), but it did not include a re-evaluation by the physician.
Patient # 10 was admitted July 21, 2010. The annual physical exam was completed on July 20, 2011 by the Certified Physician Assistant (PAc), but it did not include a re-evaluation by the physician.
Patient # 12 was admitted June 3, 2009. The annual physical exam was completed on May 26, 2011 by the Certified Physician Assistant (PAc), but it did not include a re-evaluation by the physician.
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Plan of Correction
Program Director and Clinic Supervisor will provide training to the Medical Director and PAc on completing the annual physical exam including the full documentation of a re-evaluation on the patient. If the annual physical exam is completed by the Certified Physician Assistant (PAc), it will be reviewed and signed by the program physician and will include a re-evaluation by the physician. This will be monitored by the program director and/or the clinical supervisor. These staff have been advised verbally and a comprehensive training will be conducted within 30 days.
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715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on the review of patient records and administrative documentation, the facility failed to ensure the psychosocial evaluations were a clinical assessment of the historical data collected in four of five patient records.
The findings include:
Twenty one patient records were reviewed on August 2-4, 2011. Five patient records were reviewed for psychosocial evaluations.
Patient records # 2, 17, 19 and 21 had psychosocial documents that contained a repeat of the data, patient reported commentary and no clinical assessment of the collected historical data.
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Plan of Correction
Program Director and Clinic Supervisor will provide training to all clinical staff on ensure the psychosocial evaluations where a clinical assessment of the historical data. Furthermore the clinician will give an accurate portrayal of their clinical impression of the patient during psychosocial evaluation. This process will be monitored by the clinical supervisor. Clinical staff currently has been advised verbally and a comprehensive training will be conducted within 30 days. |