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 May 19-21, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House PA was found not to be in compliance with the applicable chapters of 4 PA Code and 28 PA Code which
pertain to this facility. Deficiencies were identified during this inspection and a plan of correction is due on June 23, 2009.
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Plan of Correction
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of administrative documentation and discussion with facility staff, the facility failed to ensure at least one hour of physician time for every ten patients on a weekly basis.
The findings include:
The administrative documentation was reviewed on May 19 and May 21, 2009. This included the physician work hours for February, March and April (2009) on May 19, 2009. The Certified Registered Nurse Practitioner (CRNP) work hours were reviewed on May 21, 2009. During the months of February and March, the CRNP took time off and these hours were not picked up by either physician, according to the physician work hours submitted.
During the week ending February 21, 2009, the CRNP worked 24 hours, the physician worked 17 hours bringing to a total of 41 hours to cover a census of at least 485. A total of 48.5 physician hours was required.
During the week ending March 21, 2009, the CRNP worked 24.5 hours, the physician worked 17 hours for a total of 41.5 hours of physician time to cover a census of 493 patients. A total of 49.30 hours of medical services was required.
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Plan of Correction
Program Director will set up a contract with an outside agency to cover Nurse Practitioner vacation hours. This contract will be set up by July 31, 2009. Program Director will monitor for compliance. |
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 complete discharge summaries in four of six patient records, and within the seven days of discharge in one other patient record.
The findings include:
Thirty patient records were reviewed on May 19-21, 2009. Discharge summaries were reviewed for completion in six patient records. The discharge summaries for patients # 19, 20, 21 and 23 did not document the reasons for admission into the treatment program. The services offered to the patient was not documented in patient records # 20, 21 and 23.
In addition, patient # 22 was discharged on March 11, 2009 and the discharge summary was not completed until March 23, 2009, five days late.
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Plan of Correction
An in-service training on discharge summaries was completed on June 1, 2009. This training, given by our clinical supervisor, included documenting reasons for admission to the program, documenting services offered to the patient while in treatment and completing the discharge summaries in the appropriate time period. Clinical supervisor will monitor for compliance throughout the year. |
715.29(5) LICENSURE Exceptions
A narcotic treatment program is permitted, at the time of application or any time thereafter, to request an exception from a specific regulation.
(5) If the exception relates to a specific patient, the narcotic treatment program shall maintain documentation of the exception in the patient 's record.
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Observations
Based on the review of patient records, the facility failed to comply with the conditions of the exception granted by the Division regarding six day and thirteen day take-home privileges in two of three patient records.
The findings include:
Thirty patient records were reviewed May 19-21, 2009. Three patient records were reviewed for compliance to the terms stipulated in the exception approval. Patients on six day and thirteen day status based on the exception must have quarterly call backs (an unscheduled return to the facility within 24 hours) that includes an inventory of patient's remaining take home supply, drug testing or methadone plasma levels, and a review as to whether the reduced take-home schedule should continue.
Patient # 26 was granted an exception 12-26-08 for 13 take home bottles. There were no documented call backs since the exception was granted.
Patient # 28 was granted an exception in January 2008. The call back due by 3-19-09 was not completed. Documentation by the clinician indicated an attempt to reach the patient on 3-31-09 was made without response by the patient. There was no further documentation that this was addressed with the patient or that another call back was done.
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Plan of Correction
Random call-backs will be done quarterly for every patient who has bi-weekly, six-day or thirteen-day privilege status without exception starting immediately. An in-service training will be conducted by our nurse manager on call-backs. This training will include how to conduct a call-back, how to write a call-back note and how to follow-up with a call-back that was not able to be done. The training will be done by July 1, 2009. The clinical supervisor will monitor for compliance. |