INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 21-23, 2014 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 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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709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on the review of client records, it was determined that the written procedures for the management of treatment services did not address the presence of children in therapeutic treatment groups and did not address the care and monitoring of those children during the treatment groups.
The findings include:
Twenty client records were reviewed on October 21-23, 2014. Progress notes were reviewed for all twenty client records reviewed. The facility's current written procedures for the management of treatment services do not address the presence of children in group treatment sessions and do not address the care and monitoring of those children during those sessions. Consequently, written policies and procedures that would permit the presence of children in group treatment sessions have not been approved by the Department.
Client # 11 was admitted on July 3, 2013. Progress notes dated August 15 and September 17, 2014 identified that the client's child had been present in the treatment group. It was documented in the progress note dated August 15, 2014, that the child had participated in a group project with her mother.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will work with home office to develop written procedures for the management of treatment services for the presence of children in group treatment sessions. This shall include addressing the care and monitoring of children while in group. Each clinician will make sure that there are no children in attendance in groups. The Clinical Supervisor will monitor compliance. The Program Director will do sporadic checks to monitor compliance. |
715.16(c)(3)(i-viii) LICENSURE Take-home privileges
(c) A narcotic treatment program shall require a patient to come to the narcotic treatment program for observation daily or at least 6 days a week for comprehensive maintenance treatment, unless a patient is permitted to receive take-home medication as follows:
(3) A narcotic treatment program may permit a patient to reduce attendance at the narcotic treatment program for observation to one time weekly and receive no more than a 6-day take-home supply of medication when in the reasonable clinical judgment of the narcotic treatment physician, which is documented in the patient record:
(i) A patient demonstrates satisfactory adherence to narcotic treatment program rules for at least 3 years.
(ii) A patient demonstrates substantial progress in rehabilitation.
(iii) A patient demonstrates responsibility in handling narcotic drugs.
(iv) A patient demonstrates that rehabilitation progress would improve by decreasing the frequency of attendance for observation.
(v) A patient demonstrates no major behavioral problems.
(vi) A patient is employed, is actively seeking employment, attends school, is a homemaker or is considered unemployable for mental or physical reasons.
(vii) A patient is not known to have abused alcohol or other drugs within the previous year.
(viii) A patient is not known to have engaged in any criminal activity within the previous year.
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Observations
Based on the review of patient records, the facility failed to document, that a patient with a 6- day take home supply of medication, had demonstrated satisfactory adherence to narcotic treatment program rules for at least 3 years, in one of three patient records.
The findings include:
Twenty methadone patient records were reviewed on October 21-23, 2014. Three patient records reviewed were permitted 6-day take home supplies of medication. There was no documentation that patient # 8 had demonstrated satisfactory adherence to a narcotic treatment program rules for at least 3 years.
Patient # 8 was admitted on 1/21/14 as a transfer from another narcotic treatment facility. The patient had entered the transferring facility on August 2, 2013. The patient had transferred in with take home medication and was permitted to continue the 6- day take homes upon admission. There was no documentation that the patient had demonstrated satisfactory adherence to narcotic treatment program rules for at least 3 years prior to permitting the patient to receive 6- day take home supply of medication.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 10/24/14 the mentioned patient was decreased to tri-weekly take homes according to the regulations.The Clinical Supervisor held a meeting on 11/3/14 to ensure all clinicians are aware of the importance that the patient has demonstrated satisfactory adherence to the narcotic program rules and regulations for 3 years. All transfer patients into our facility will not receive any status until all the clinical supervisor reviews the transfer paperwork to make sure the patient is eligible for take home status. Once eligibility is confirmed, the medical director will review material to ensure the patientis eligibile, then he will place an order in the chart. The clinical supervisor will monitor all patient transfer records to ensure they adhere to the treatment program rules. The program Director will do sporadic checks to minitor compliance. |