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 February 6-8, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House -NC 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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715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the facility failed to obtain an informed, voluntary, written consent prior to the administration of a narcotic agent for maintenance treatment.
The findings include:
Twenty four patient records were reviewed on February 6-8, 2012. Ten patient records were reviewed for the completion of an informed, voluntary written consent prior to the administration of a narcotic agent. The facility failed to document the completion of an informed, voluntary, written consent prior to the administration of a narcotic agent in patient records # 2 and 17.
Patient # 2 was admitted into treatment on November 14, 2011. The patient received their initial dose of methadone on November 14, 2011. The informed, voluntary, written consent was signed by the patient on November 29, 2011.
Patient # 17 was admitted into treatment on August 2, 2011. The patient received their initial dose of methadone on August 2, 2011. The informed, voluntary, written consent was signed by the patient on August 11, 2011.
The facility director and clinical supervisor were interviewed on February 7, 2012 and confirmed the aforementioned information.
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Plan of Correction
Clinical Supervisor will conduct training during staff meeting to go over the consent form the importance of having it signed before admission. The medical director will check to see if form is signed before entering order for first dose. This will be monitored through chart audits. Clinical Supervisor and the Program Director. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on the review of patient records, the facility failed to document the attempt or completion of patient follow up contact as per facility policy, within 14 and 30 days after discharge, in four of twelve patient records.
The findings include:
Twenty four patient records were reviewed on February 6-8, 2012. Twelve patient records required documentation of an attempt or completion of a follow up contact within 14 and 30 days after discharge. The facility failed to document follow up contact within 14 and 30 days after discharge in patient records # 9, 13, 17 and 23.
Patient # 9 was admitted November 6, 2010 and discharged on August 5, 2011. The follow up contact was due to be completed on August 19, 2011 and September 5, 2011. The follow up was not completed until August 22, 2011 and September 12, 2011.
Patient # 13 was admitted October 17, 2008 and discharged on May 20, 2011. The follow up contact was due to be completed on June 3, 2011 and June 20, 2011. The follow up was not completed until June 9, 2011 at which time a follow up phone call was made and a follow up letter mailed to client #13.
Patient # 17 was admitted February 12, 2010 and discharged on June 21, 2011. The follow up contact was due to be completed on July 5, 2011 and July 21, 2011. The follow up was not completed until July 9, 2011 and July 21, 2011.
Patient # 23 was admitted March 2, 2009 and discharged on November 13, 2011. The follow up contact was due to be completed on November 27, 2011 and December 13, 2011. The follow up was not completed until November 22, 2011 and December 29, 2011.
Interviews took place with the facility director and clinical supervisor on February 8, 2012 at which time the aforementioned information was confirmed.
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Plan of Correction
Clinical Supervisor will conduct a training on the Discovery House Policy on Dicharge follow-up which will include the time frames for completion within 14 and 30 days after discharge. Follow up will be done through chart audits by the clinical supervisor. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to document an annual evaluation of each patient's status in two of four patient records.
The findings include:
Twenty four patient records were reviewed on February 6-8, 2012. Four patients were required to have documentation of an annual evaluation. The facility failed to document an annual evaluation of each patient's status in patient records # 5 and 6.
Patient #5 was admitted to treatment on June 8, 2009. An annual evaluation of the patient's status was due to be completed by June 8, 2011. There was no documentation of an annual evaluation in patient record #5.
Patient #6 was admitted to treatment on October 29, 2008. An annual evaluation of the patient's status was due to be completed by October 29, 2011. An annual evaluation was completed on October 8, 2011; however, it lacked an evaluation of employment, education and training, legal standing, substance abuse, financial management abilities, physical and emotional health, fulfillment of treatment objectives, and family and community support. Instead, "patient reports it is the same" was written as a response to several of the required areas to be evaluated.
Interviews with the facility director and clinical supervisor on February 7, 2012 at which time the aforementioned information was confirmed.
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Plan of Correction
Clinical supervisor will conduct a trainig on the Annual Evaluation to include timeframes for completion and the contents of the note to include more informaton about the patient such as employment hx, education, physical and emotional health ect. This will be monitored through chart audits by the clinical supervisor. |