INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection, and a methadone monitoring inspection conducted on December 21-22, 2016, 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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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
The facility has a total of 3 exits. The facility used all 3 exits for all fire drills conducted from 12/17/2015 through 11/29/2016.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Program Director an Program Manager had a meeting and effective December 26,2016 Discovery House shall prepare alternate exit routes to be used during fire drills. The facility currently used all 3 exits for all fire drills. The program manager will monitor compliance and the facility director will do sporadic checks to ensure compliance. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
The facility failed to obtain informed voluntary consents containing all of the necessary information in 2 patient records.
Patient #11, a female patient, was admitted for narcotic treatment on 11/03/2016, but the facility did not obtain a voluntary consent form signed by the patient that included information that methadone is transmitted to unborn children.
Patient #12, a female patient, was admitted for narcotic treatment on 09/27/2016, but the facility did not obtain a voluntary consent form signed by the patient that included information that methadone is transmitted to unborn children.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Program Director will work with Acadia and the Regional Director to revisit the use of the old consent to treat form which contained information for pregnant females than methadone is transmitted to the unborn child. Effective immediately the Program Director will set up meetings with Acadia to get the voluntary consent form for pregnant females included in the forms section of the chart. The Program Director will work with the Regional Director to ensure this is in compliance by 1/31/2017. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
The facility failed to document a random urinalysis at least monthly in one patient record.
Patient #10 was admitted on August 19, 2015 and discharged on 10-17-2016. There was no documentation of a complete urinalysis for the month of April 2016.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Program Director held meeting on 12/23/16 with the medical staff explaining the importance of making sure that all patients have a random monthly drug screen. Effective 12/30/2016 each Discovery House patient will have a random monthly drug screen. This will be monitored through the monthly drug screen reports. The Nurse manager will run the reports to ensure compliance. The Program Director will do sporadic checks to ensure compliance. |
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
The facility failed to ensure that all medication orders were properly documented in 1of 10 patient records reviewed.
Patient #12 was given a 13 day supply of take-home methadone from 12/18/2016, through 12/30/ 2016, but the order for the take-home methadone was not signed by a physician.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Program Director held meeting on 12/23/16 with the medical staff explaining the importance of making sure that all medical orders are signed by the medical director. Effective immediately,12/23/2016 the physician will sign the order then will reopen the order and make sure that his signature is present. The nurse manager will monitor compliance and the Program Director will do sporadic check to ensure 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
The facilty failed to transfer the required patient files in one of two patient record which were reviewed on December 20-21, 2016.
Patient # 8 was discharged as a transfer to another narcotic treatment facility on November 28, 2016. There was no documentation of the required patient files being transferred to the receiving facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director and Clinical Supervisor held a meeting on 12/23/16 explaining the importance of sending the transferring documents of the required patient to the receiving facility and keeping the transmittal paper. Effective immediately all patient that are transferred out will have their transferring documents placed in their charts along with the transmittal paper. The Clinical Supervisor will monitor compliance when doing the discharge audit and document that it has been sent. The Program Manager will do sporadic checks to ensure compliance. |