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 26-28, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center for Behavioral Health- PA, 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 nine of the seventeen weeks reviewed.
The findings include:
The Physician's and Certified Registered Nurse Practitioners' time sheets and the weekly census for the period of February 19 to June 15, 2012 were reviewed on June 26-28, 2012. The facility provided insufficient onsite physician hours during the months of February, March, April, May and June, 2012.
During the week of February 27, 2012, the patient census was 405. The facility was required to provide at least 40.5 physician hours. There were 38.65 physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of March 5, 2012, the patient census was 390. The facility was required to provide at least 39 physician hours. There were 22.67 physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of March 12, 2012, the patient census was 382. The facility was required to provide at least 38.2 physician hours. There were 22.67 physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of March 19, 2012, the patient census was 371. The facility was required to provide at least 37.1 physician hours. There were 23.62 physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of April 2, 2012, the patient census was 361. The facility was required to provide at least 36.1 physician hours. There were 29.57 physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of April 9, 2012, the patient census was 357. The facility was required to provide at least 35.7 physician hours. There were 29.68 physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of April 23, 2012, the patient census was 352. The facility was required to provide at least 35.2 physician hours. There were 32.28 physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of May 28, 2012, the patient census was 331. The facility was required to provide at least 33.1 physician hours. There were 29.79 physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of June 11, 2012, the patient census was 332. The facility was required to provide at least 33.2 physician hours. There were 30.70 physician hours documented. The amount of physician hours documented did not meet the required hours.
The facility director was interviewed on June 28, 2012 and confirmed the findings.
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Plan of Correction
In order to obtain compliance with PA Department of Health Regulations, Program Director has been diligently searching for a permanent Medical Director by using various sources of advertising, in addition to recent recruitment of a head hunter. Until compliance is met with regulations to provide 1 hour of physician time for every 10 patients, Discovery House Cranberry has ceased new admissions and begun a waiting list.
The Division will be contacted once a permanent Medical Director/physician has been hired.
Program Director and Human Resources are working in conjunction to remedy this deficiency in a timely manner.
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715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on the review of administrative documentation, the facility failed to ensure that one-third of all required narcotic treatment physician time was provided by a narcotic treatment physician in eight of the seventeen weeks reviewed.
The findings include:
The Physician's and Certified Registered Nurse Practitioners' time sheets and the weekly census for the period of February 19 to June 15, 2012 were reviewed on June 26-28, 2012. The facility provided insufficient onsite physician hours during the months of February, March, April, May and June, 2012.
During the week of February 20, 2012, the patient census was 405. The facility was required to provide at least 40.5 physician hours of which 13.66 hours required that time was provided by a narcotic treatment physician. There were 5 narcotic treatment physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of March 5, 2012, the patient census was 390. The facility was required to provide at least 39 physician hours of which 13.50 hours required that time was provided by a narcotic treatment physician. There were 5 narcotic treatment physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of April 2, 2012, the patient census was 361. The facility was required to provide at least 36.1 physician hours of which 12.03 hours required that time was provided by a narcotic treatment physician. There were 6 narcotic treatment physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of April 9, 2012, the patient census was 357. The facility was required to provide at least 35.7 physician hours of which 11.90 hours required that time was provided by a narcotic treatment physician. There were 6 narcotic treatment physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of April 23, 2012, the patient census was 352. The facility was required to provide at least 35.2 physician hours of which 11.73 hours required that time was provided by a narcotic treatment physician. There were 9.5 narcotic treatment physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of May 28, 2012, the patient census was 331. The facility was required to provide at least 33.1 physician hours of which 11.03 hours required that time was provided by a narcotic treatment physician. There were 6 narcotic treatment physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of June 4, 2012, the patient census was 333. The facility was required to provide at least 33.3 physician hours of which 11.10 hours required that time was provided by a narcotic treatment physician. There were 10.5 narcotic treatment physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of June 11, 2012, the patient census was 332. The facility was required to provide at least 33.2 physician hours of which 11.06 hours required that time was provided by a narcotic treatment physician. There were 10 narcotic treatment physician hours documented. The amount of physician hours documented did not meet the required hours.
The facility director was interviewed on June 28, 2012 and confirmed the findings.
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Plan of Correction
In order to obtain compliance with PA Department of Health Regulations, Program Director has been diligently searching for a permanent Medical Director by using various sources of advertising, in addition to recent recruitment of a head hunter. Until compliance is met with regulations to provide 1 hour of physician time for every 10 patients, Discovery House Cranberry has ceased new admissions and begun a waiting list.
The Division will be contacted once a permanent Medical Director/physician has been hired.
Program Director and Human Resources are working in conjunction to remedy this deficiency as quickly as possible.
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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 dosing observation, the facility failed to physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR Part 2, Subpart B, 2.22 (relating to notice to patients of Federal confidentiality requirements) and 28 Pa. Code 709.28 (relating to confidentiality).
The findings include:
During the observation of the methadone dispensing on June 27, 2012 between 9:45 AM and 9:50 AM, patients were observed placing returned take home bottles in the trash. The trash in this can is placed in with the general trash; which could be accessed by the public. It was observed that several bottles had been placed in the trash with the patient's first and last names clearly visible. The practice was that the patient had a choice as to whether or not they blackened out their identifying information. If the patient chose not to blacken out their information, the bottles would be thrown into the general trash with the identifying information visible. This practice did not ensure that the patient's confidentiality was physically secure and maintained, as required by Federal and State regulations.
The dosing nurses was interviewed on June 27, 2012 after the completion of methadone dispensing. The nurses confirmed that the take home bottles are placed in the trash which could be accessed by the public and that if the patient did not blacken out their identifying information, the bottles would be thrown into the general trash with the information visible.
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Plan of Correction
In order to comply with PA Department of Health regulations to preserve patient confidentiality, the dispensing nurses immediately began to require all patient identifying information to be removed from returned take home medication bottles before disposal. If a patient choses not to remove his/her identifying information, the dispensing nurses will complete this task.
Program Director will complete spot checks to ensure this task is being completed and will monitor to ensure patient confidentiality is maintained.
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