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 16-18, 2010 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 and a plan of correction is due on September 8, 2010.
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Plan of Correction
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715.10(d) LICENSURE Pregnant patients
(d) Within 3 months after termination of pregnancy, the narcotic treatment physician shall enter an evaluation of the patient 's treatment status into her record and state whether she should remain in comprehensive maintenance treatment or receive detoxification treatment.
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Observations
Based on the review of patient records, the narcotic treatment program failed to document, within three months after the termination of pregnancy, whether or not the patient should continue maintenance or receive detoxification treatment in one of two patient records.
The findings include:
Twenty three patient records were reviewed August 16-18, 2010. An evaluation of the patient's treatment status within three months after termination of pregnancy was required in two patient records. The narcotic treatment program, specifically the physician, did not document this evaluation in patient record # 4
Patient # 4 was admitted on June 29, 2009 and gave birth in February 2010. The evaluation of the patient's treatment status was due by May, 2010. The documentation in the patient 's record, completed by the narcotic treatment physician, did not include an evaluation of the patient's status and did not state whether she should remain in comprehensive maintenance treatment or receive detoxification treatment.
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Plan of Correction
Medical Director reviewed regulation and requirements of documentation needed for evaluation of treatment status after termination of pregnancy. Medical Director will complete a thorough evaluation of patient's treatment status within three months after termination of pregnancy and identify whether patient should remain in comprehensive methadone maintenance treatment or receive detoxification treatment. Program Director will monitor documentation and oversee to ensure compliance with regulation. |
715.13(a) LICENSURE Patient identification
(a) A narcotic treatment program shall use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
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Observations
Based on the observation of the dosing area, the facility failed to follow the facility's policy for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
The finding include:
The dosing area was observed from 8:30 AM to 9 AM. Per policy, patients are to remove hats and sunglasses prior to dosing. At approximately 8:45 AM, patients at windows # 1, 2 and 3 were all observed with hats on. The three patients did not remove their hats prior to being dosed.
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Plan of Correction
Each Nursing Associate has reviewed the Discovery House Policy "Administration of Medication" to correctly identify patient prior to administration of an agent. Nursing Associates will begin to comply immediately. Patients will be asked to remove hats and sunglasses before medication is administered. Program Director will perform spot checks to ensure policy is being followed. Program Director will oversee and monitor for compliance. |
715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on a review of patient records and an interview with the facility director, the narcotic treatment program failed to document what materials were sent to the receiving narcotic treatment program in one of two patient records.
The findings include:
Twenty three patient records were reviewed on August 16-18, 2010. Two patient records required documentation of the materials sent to the receiving provider of the transfer. In patient record # 23, there was no documentation of the materials sent to the receiving narcotic treatment program.
An interview with the facility director on August 18, 2010 confirmed that there was no documentation of the materials sent to the receiving narcotic treatment program.
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Plan of Correction
Regulation will be reviewed with all Associates during Associate meeting on 08/26/2010. Associates will document what materials were sent to the receiving narcotic treatment program either by "disclosure" section in patient's electronic chart, or by attaching fax confirmation to materials sent and filing in patient's paper chart. Program Manager will audit chart within 7 days of transfer to ensure documentation is in place. Program Director will oversee and monitor. |