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 June 18 to 20, 2013, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House CU, 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.
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Plan of Correction
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of administrative documentation, the facility failed to provide at least one hour of physician time a week, on site for every ten patients for seven of the twenty-two weeks reviewed.
The findings include:
Physician time sheets for the weeks of January 12, 2013 to June 8, 2013 were reviewed on June 18, 2013. Twenty-two weeks were reviewed along with the average census for those weeks. Seven weeks documented insufficient onsite physician hours.
During the week of January 26, 2013, the patient census was 314 and the facility documented 24 of the required 31.4 physician hours.
During the week of February 23, 2013, the patient census was 321 and the facility documented 24 of the required 32.1 physician hours.
During the week of March 2, 2013, the patient census was 323 and the facility documented 32.2 of the required 32.3 physician hours.
During the week of March 9, 2013, the patient census was 326 and the facility documented 26 of the required 32.6 physician hours.
During the week of March 30, 2013, the patient census was 330 and the facility documented 25 of the required 33 physician hours.
During the week of May 4, 2013, the patient census was 333 and the facility documented 33.2 of the required 33.3 physician hours.
During the week of May 11, 2013, the patient census was 334 and the facility documented 26 of the required 33.4 physician hours.
The findings were reviewed and confirmed with the Facility Director.
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Plan of Correction
On 6/28/23 there was a training with the medical staff regarding the importance of having documented medical coverage. Effective 6/29/13, there was an add placed in the local newspaper to find medical coverage for our current PA-C when she is off. The Program Director will check census at the beginning of each week and make the medical staff aware of the time needed. The Program Director will monitor time sheets for compliance. |
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 the review of patient records, the facility failed to contact the previous narcotic treatment facility for the patient's treatment history in two of two patient records reviewed.
The findings include:
Sixteen patient records were reviewed on site. Two patient records required contacting the prior narcotic treatment facility for the previous treatment history that was reported by the patient.
Patient records # 7 and #10 contained documentation the patients had received previous narcotic treatment services at another narcotic treatment program. The facility failed to document any attempt to obtain the patients' prior treatment history from the attended narcotic treatment facilities.
The findings were reviewed and confirmed with the Facility Director.
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Plan of Correction
A training was held on 6/20/2013 explaining the importance of obtaining patients prior treatment records from narcotic treatment facilities. Each counselor will document any attempt to obtain records. Each counselor will also keep the fax sheet for documented attempt and place in patient file. The c
Clinical Supervisor and Lead Counselor will monitor compliance.
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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 the review of patient records, the facility failed to maintain the confidentiality in accordance with 42 CFR 2.22 in two of eleven records reviewed. Additionally, the facility exceeded 4 Pa. Code, Subsection 255.5(b) in three of eleven records reviewed.
The findings included:
Sixteen patient records were reviewed on site. Eleven records were reviewed regarding release of information documentation. The facility failed to maintain the confidentiality of all patient records in five records, # 11, 12, 14, 15 and 16.
Patient record # 11 contained a consent to release for a legal entity that permitted the release of dose level and treatment plan. These items exceeded 4 Pa. Code, Subsection 255.5(b) for what is permitted to be released to a legal entity.
Patient record # 12 contained two consents to release for legal entities that permitted the release of medication history and current dose. These items exceeded 4 Pa. Code, Subsection 255.5(b) for what is permitted to be released to a legal entity.
Patient record # 14 contained a consent to release for a transportation entity that permitted the release of "information about patient's treatment that will assist in appeals decision for transportation." This a general statement of disclosure. Information to be disclosed must be specifically identified.
Patient record # 15 contained a consent to release for a legal entity that permitted the release of the treatment plan. This item exceeded 4 Pa. Code, Subsection 255.5(b) for what is permitted to be released to a legal entity.
Patient record # 16 contained a consent to release for a transportation entity that permitted the release of current dose level. The purpose of the consent to release was coordination of transportation. This item exceeded information needed to complete the purpose.
The findings were reviewed and confirmed with the Facility Director.
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Plan of Correction
A training was held on 6/20/13 explaining the importance of each patient confidentiality. 42CFR and 255.5 were explained during the meeting and the information that is allowed to be released to the different entities. All old releases will be checked to ensure they do not exceed 255.5. New releases being completed will be checked by the Clinical Supervisor and Lead Counselor for compliance. All other releases will be checked to ensure they do not exceed 255.5. The Program Director will do sporadic checks to monitor compliance. |
715..23(b)(1) LICENSURE Patient records
(b) Each patient file shall include the following information:
(1) A complete personal history.
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Observations
Based on a review of the patient records, the facility failed to document a complete personal history in six of six records reviewed.
The findings include:
Sixteen patient records were reviewed on site. Six patient records were reviewed for a personal history that included prior treatment, family, legal, employment/vocation, educational, military, recreational and sexual history. Patient records # 6, 7, 8, 10, 11 and 12 lacked detail in the personal histories by answering with one or two word answers and documenting a history that included only the past 30 days.
Patient # 6 was admitted on 11/21/2012 and discharged on 5/13/2013. The facility failed to document a detailed educational history and sexual history.
Patient # 7 was admitted on 5/8/2013. The facility failed to document a sexual history.
Patient # 8 was admitted on 2/20/2013. The facility failed to document a sexual history.
Patient # 10 was admitted on 2/5/2013. The facility failed to document legal history, a detailed employment/vocational history, detailed educational history, and sexual history.
Patient # 11 was admitted on 2/26/2013. The facility failed to document legal history, a detailed educational history, and sexual history.
Patient # 12 was admitted on 9/21/2012. The facility failed to document a sexual history.
The findings were reviewed and confirmed with the Facility Director.
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Plan of Correction
A training was held on 6/20/13 by the clinical supervisor and lead counselor regarding the importance of providing personal history that includes detailed information in the area of family, legal, employment, vocational, educational, military, recreational, prior treatment, clients perception of drug use , family drug abuse history and sexual history. Effective 7/30/13 there will be a check list included in the intake packet for employees to follow to ensure that personal histories are detailed. We will also be working with Home Office on creating more space on the form. Assessments will be checked by the clinical supervisor and lead counselor prior to the counselor signing on them. The clinic director will do sporadic checks to monitor 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.
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Observations
Based on the review of patient records, the facility failed to document a physical examination that included a general appearance that was unique to the patient in thirteen of thirteen records reviewed.
The findings include:
Sixteen patient records were reviewed on site. Thirteen patient records were reviewed for initial and annual physical examinations that included documentation of the patient's general appearance. Patient records # 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16 had identical general appearances. Every physical examination contained the following statement documented for the patient's general appearance, "alert, well oriented, normal speech pattern and gait." There were no additional comments by the physician that addressed the patient's general appearance.
The findings were reviewed and confirmed with the Facility Director.
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Plan of Correction
On 6/19/13, the initial PE form in the computer was changed. A training was held on 6/24/13 with the physician by the program director regarding the general appearance in each patient chart not being unique to each patient. Effective 6/19/13 the template " alert, well oriented, normal speech pattern and gait" was removed allowing the physician to document his own comments for each patients in their record. The program director will do sporadic checks to monitor compliance.
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