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 December 11, 2012, through December 13, 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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715.16(a)(4) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(4) A narcotic treatment physician may rescind take-home medication privileges.
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Observations
Based on the review of patient records, the facility failed to ensure the narcotic treatment physician rescinded the take-home medication privilege in three of four patient records.
The findings include:
Thirty-one patient records were reviewed on December 11, 2012 through December 13, 2012. Two records reviewed included documentation pertaining to the rescinding of take-home medication privileges. Two additional records were reviewed that included documentation regarding the assessment of take home status. The facility failed to ensure the narcotic treatment physician rescinded take-home medication privileges, # 18, 23 and 24.
Patient # 18 was admitted on 7/12/2011. According to the Script History Report for this record, the document listed on 4/16/2012 indicated that there were "no take homes per counselor".
Patient # 23 was admitted on 8/17/2010. A progress note documented by the counselor on 7/1/2012 addressed the AWOL (Absence without leave) status of the patient. The plan stated the patient was to retain take-home status at this time. There was no physician documentation in the patient record that pertained to the patient's absence from the facility.
Patient # 24 was admitted on 3/29/2010. A progress note documented by the counselor on 11/15/2012 addressed the client's failure to comply with the medication call back. The plan stated the patient will continue to have take home status at this time. There was no physician documentation in the patient record that pertained to the determination of take-home status following the patient's failure to respond to a medication call back.
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Plan of Correction
In order to ensure 715.16(a)(4) is followed, the clinical and medical associates will be trained to complete documentation that reflects the Medical Director made the determination of rescinding take home status.
Clinical supervisor will monitor documentation and Program Director will oversee. |
715.16(d)(1-3) LICENSURE Take-home privileges
(d) A narcotic treatment program may make exceptions to the requirements in subsection (c) relating to the length of time of satisfactory adherence to narcotic treatment program rules and number of days of take-home medication when, in the reasonable clinical judgment of the narcotic treatment physician, which is documented in the patient record:
(1) A patient has a permanent physical disability.
(2) A patient has a temporary disability.
(3) A patient has an exceptional circumstance such as illness, personal or family crisis, or travel which interferes with the patient 's ability to conform to the applicable mandatory attendance schedules. In all cases, the patient shall demonstrate an ability to responsibly handle narcotic drugs.
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Observations
Based on the review of patient records, the facility failed to ensure that the physician completed the exceptional circumstance documentation in two of three patient records reviewed.
The findings include:
Thirty-one patient records were reviewed on December 11, 2012 through December 13, 2012. Three patient records were reviewed for exceptional circumstance take home medication request. The facility failed to document exceptions that meet the regulation in records # 23 and 24.
Patient # 23 was admitted on 8/17/2010. According to the Script History Report for this record, the document listed on 5/29/2012 that the patient was requesting early weekly status. The patient was assessed to be 8 point compliant. The patient met the requirements and would complete quarterly call backs until reaches the 3 year mark in treatment. The record log shows this patient attends clinical services regularly on take home dose days. Based on the review of the record, the facility failed to document the exceptional circumstance for the take home schedule.
Patient # 24 was admitted on 3/29/2010. According to the Script History Report for this record, the document listed on 12/7/2011 the patient was given an exception for 6 day take home status due to physical limitations. Based on the review of the record, the exceptional circumstance included paralysis. The exception was rescinded when the patient failed to maintain a zero balance.
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Plan of Correction
In order to comply with regulation 715.16(d)(1-3), the medical director will be trained to only approve exceptions when a patient is found to have a permanent or temporary physical disability and exceptional circumstances. Documentation will be placed that clearly identifies the exception details.
Program Director will monitor and oversee.
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715.16(f) LICENSURE Take-home priveleges
(f) An exception granted under subsection (d) shall continue only for as long as the temporary disability or exceptional circumstance exists. When a patient is permanently disabled, that case shall be reviewed at least annually to determine whether the need for the exception still exists.
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Observations
Based on the review of patient records and a review of administrative documentation, the facility failed to review annually to determine whether the need for the exception for 13-day take-home still existed.
The findings include:
Thirty-one records were reviewed on December 11, 2012 through December 13, 2012. The Methadone Monitoring Questionnaire documented that six patients at the facility had 13-day take home privileges due to an exception. One record was reviewed for documentation that the 13-day take home privilege still existed annually, # 22.
Patient # 22 was admitted on 7/3/1997. The initial documentation of the 13-day take-home justification was dated 10/3/2005 stating the patient was disabled, worked part time and was requesting reduced attendance due to the need to get home to get his son to school as a single parent. A review of patient record documentation revealed that the facility has failed to annually review the status of patient # 22 in an effort to determine if justification continues to exist for 13 day take-home status.
An interview with the facility director confirmed that the annual justification review was not documented.
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Plan of Correction
To ensure compliance to this regulation, all patients who are permanently disabled and have an exception to take home status will be reviewed at least annually to determine whether the need for the exception still exists.
The Clinical Supervisor will coordinate with the treating physician to obtain justification for continued exception. Medical director will review documentation and make determination to continue exception at least annually.
Program Director will perform an audit to ensure an annual review is being completed and determination is documented.
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715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on the review of patient records, someone other than the narcotic treatment physician documented the patient's subsequent dose and schedule in one of two records reviewed.
The findings include:
Thirty-one patient records were reviewed on December 11, 2012 through December 13, 2012. Two patients were administratively terminated. The records included administrative withdrawal notices.
Patient # 25 received an administrative withdrawal notice on August 30, 2012. The notice documented the patient's dose would be decreased 3 milligrams per day until September 23, 2012. The record was reviewed for documentation of the narcotic treatment physician initiating the dose change. The narcotic treatment physician wrote an order on September 13, 2012, approximately two weeks after the administrative withdrawal notice, stating the patient was to begin a 21 day administrative detox. There was no documentation in the record prior to the administrative withdrawal notice being given to the patient that showed the narcotic treatment physician made the decision to decrease the patient's dose 3 milligrams per day.
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Plan of Correction
To correct this deficiency, the administrative withdrawal notice form has already been changed to require the Medical Director's signature. The Medical Director's signature will be captured before reviewing this form with the patient.
Program Director will monitor and oversee. |
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 transfer the required patient files in one of two patient records.
The findings include:
Thirty-one patient records were reviewed on December 11, 2012 through December 13, 2012. Two patient records required the facility transfer specific patient files to the receiving narcotic treatment program as part of the transfer process. One patient record did not document transfer of the specified files, # 27.
Patient # 27 was discharged as a transfer to another narcotic treatment facility on October 1, 2012. There was no documentation in the record that the required patient files were transferred to the receiving facility.
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Plan of Correction
During the next treatment team meeting, all clinicians will be reminded to document materials that are sent to transferring facility to comply with regulation 715.20(1).
Clinical Supervisor will monitor through supervision and Program Director will complete audits to ensure continued compliance. |
715.21(1)(i-iv) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
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Observations
Based on the review of patient records, the facility failed to restrict the reasons for involuntary termination to the reasons allowed by regulation in one of two patient records.
The findings include:
Thirty-one records were reviewed on December 11, 2012 through December 13, 2012. Two patient records were reviewed for involuntary, or therapeutic discharge. One patient record contained documentation of the patient being discharged for reasons other than those listed by regulation.
Patient # 25 was admitted on March 30, 2012 and was administratively discharged on October 4, 2012. The patient received an administrative termination notification on August 30, 2012. The reason for termination listed on the termination notification letter was for failure to make progress. The Script History Report listed an incremental order on September 13, 2012, by the narcotic treatment physician that indicated the patient was being terminated for non compliance with treatment, non compliance with counseling, dosing and benzodiazepine policy. Patient was not making progress in treatment. The facility failed to limit the reasons for termination from treatment to those permitted by the regulation.
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Plan of Correction
In order to limit reasons for involuntary termination of treatment to only those permitted by regulation, the Program Director will review and monitor the patient chart closely so that no patient is terminated from treatment for reasons other than permitted by regulation. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on the review of patient records, the facility failed to document discharge summaries that included all of the components in five of seven records reviewed.
The findings included:
Thirty-one patient records were reviewed on December 11, 2012 through December 13, 2012. Seven records were reviewed for discharge summaries. Five records were missing components of the discharge summary, # 27, 28, 29, 30 and 31.
Patient # 27 was admitted on 10/28/2011 and discharged on 10/01/2012. The record did not include medication as a service offered by the facility. As this facility is a narcotic treatment program, the medication is a significant component of the treatment services offered.
Patient # 28 was admitted on 9/23/2011 and discharged on 9/13/2012. The record did not include medication as a service offered by the facility. As this facility is a narcotic treatment program, the medication is a significant component of the treatment services offered. Additionally, discharge summaries are due within 7 days of discharge. The discharge summary was due by 9/20/2012 and dated 9/29/2012.
Patient # 29 was admitted on 6/15/2012 and discharged on 9/6/2012. The record did not include medication as a service offered by the facility. As this facility is a narcotic treatment program, the medication is a significant component of the treatment services offered.
Patient # 30 was admitted on 8/24/2011 and discharged on 10/10/2012. The record noted the reason for treatment was because the patient's opiate addiction could not be managed without methadone. This is not an individualized reason for treatment as all patients present with this issue.
Patient # 31 was admitted on 7/21/2009 and discharged on 8/6/2012. The record noted the reason for treatment was because the patient's opiate addiction could not be managed without methadone. This is not an individualized reason for treatment as all patients present with this issue.
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Plan of Correction
During the next treatment team meeting, the clinicians will be instructed to include medication as a service offered by the facility on the discharge summary.
Clinical Supervisor will review and approve the discharge summary once all of the components required in the summary are evident.
Program Director will oversee to ensure compliance with this regulation. |
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 the patient records, the facility failed to document an annual evaluation that addresses the entire evaluation period in seven of seven records reviewed.
The findings include:
Thirty-one patient records were reviewed on December 11, 2012 through December 13, 2012. Seven records were required to include an annual evaluation, # 18, 19, 21, 22, 23, 30 and 31.
Patient # 18 was admitted on 7/12/2011. The annual evaluation was documented on 7/11/2012. Substance abuse listed reduction of substance abuse and absence of substance abuse with a one word answer. The documentation for fulfillment of treatment objectives noted the patient was making progress on all treatment objectives and goals with no review.
Patient # 19 was admitted on 8/24/2011. The annual evaluation was documented on 8/30/2012. Substance abuse listed reduction of substance abuse and absence of substance abuse with a one word answer. The documentation for fulfillment of treatment objectives noted the patient was compliant with the treatment plan with no review.
Patient # 21 was admitted on 8/31/2011. The annual evaluation was documented on 8/21/2012. Substance abuse listed reduction of substance abuse and absence of substance abuse with a one word answer. The documentation for fulfillment of treatment objectives noted the patient was actively working on treatment plan goals and objectives with no review.
Patient # 22 was admitted on 7/3/1997. The annual evaluation was documented on 7/9/2012. Substance abuse listed reduction of substance abuse and absence of substance abuse with a one word answer. The documentation for fulfillment of treatment objectives noted the patient was compliant and working on goals with no review.
Patient # 23 was admitted on 8/17/2010. The annual evaluation was documented on 8/20/2012. Substance abuse listed reduction of substance abuse and absence of substance abuse with a one word answer. The documentation for fulfillment of treatment objectives noted the patient was making some progress with no review. Much of the document contained one or two word answers.
Patient # 30 was admitted on 8/24/2011. The annual evaluation was documented on 8/20/2012. Substance abuse listed reduction of substance abuse and absence of substance abuse with a one word answer.
Patient # 31 was admitted on 7/21/2009. The annual evaluation was documented on 7/16/2012. Substance abuse listed reduction of substance abuse and absence of substance abuse with a one word answer. The documentation for fulfillment of treatment objectives noted the patient was making progress on all treatment objectives with no review.
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Plan of Correction
The clinical associates had been trained to review and document a summary of the entire year of progress for each annual clinical evaluation. To prevent one word answers, the form will be changed to remove the drop down selection and allow the clinician to document the yearly progress in sentences.
The clinical supervisor will complete spot checks to monitor the documentation of the annual clinical evaluations and the Program Director will oversee.
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715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on the review of patient records and administrative documentation, the facility failed to provide documentation of incident reports involving incidents with potential for negative community reaction to the Department.
The findings include:
Administrative documentation that included the unusual incident reports was reviewed December 11, 2012. During the review of patient record # 26 documentation was found of a physical altercation on the premises. The incident reports were requested. Upon review of the reports, the incident included police involvement and medical transport. This unusual incident was not reported to the Department as required.
This was discussed with facility director who acknowledged it was not sent.
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Plan of Correction
The Program Director will review each incident report and ensure that any incident involving the authorities is documented and sent to the PA Department of Health within 48 hours. |