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 August 17-19, 2010 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 and a plan of correction is due on September 22, 2010.
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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 two of eight patient records.
The findings include:
Twenty five patient records were reviewed August 17-19, 2010. Eight patient records were reviewed for physician documentation of the basis for determining current and one year history of dependency.
Patient # 19 was admitted May 6, 2010. The only documentation by the physician for determining at least one year history of dependence was the patient statement to the physician.
Patient # 20 was admitted June 24, 2010. This patient had been treated previously and was discharged when the patient was incarcerated in April 2009. Patient's admission urine drug screen was positive only for benzodiazepines. The physician documented that the patient's admission urine drug screen was positive for opiates. There was no documentation to address the discrepancy or the physician's determination for admission.
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Plan of Correction
A training was held on 8/23/10 regarding the importance of having each narcotic treatment physician document in the patient's record the basis for the determination of current dependency and evidence of a one year history of addiction. The program director will monitor each new admission for compliance. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on the review of patient records, the facility failed to document transfer information for two of three patient records.
The findings include:
Twenty five patient records were reviewed August 17-19, 2010. Three patient records required the facility transfer the patient files with the written consent of the patient. Patient records # 1 and 2 were transferred to other treatment facilities and there was no documentation to demonstrate the files were transferred as required.
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Plan of Correction
A training is scheduled for 9/15/10, regarding the importance of transferring all the patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent. The clinical staff will place all files that were sent in the patients chart and will document in the patients chart a list of documents that were sent to the receiving clinic. The Clinical Supervisor will monitor this through discharge chart audits. The Program Director will do sporadic checks to monitor compliance. |
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, the facility failed to provided an evaluation of the historical data in five of five patient records.
The findings include:
Twenty five patient records were reviewed August 17-19, 2010. Five patient records were reviewed specifically for a psychosocial evaluation of the patient's historical data collected by staff.
Patient records # 6, 13, 15, 19 and 23 contained documentation that failed to include a composite picture or clinical assessment of the collected historical data.
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Plan of Correction
The Clinical Supervisor and the Clinical Function Leader will hold a meeting on 9/23/10 regarding the importance of having each clinician document their assessment of the historical data that was collected during the intake process. This will be monitored by the Clinical Supervisor. The Program Director will do sporadic checks to ensure compliance.
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