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 June 2 through 3, 2014, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House HA 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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715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on the review of patient records, the facility failed to verify the identity of the patient prior to the administration of an agent in one of six patient records reviewed.
The findings included:
Sixteen patient records were reviewed during the on-site inspection. Six patient records were reviewed for patient identity information. Patient record # 13 did not contain documentation that verified the patient's identity including patient name, address and date of birth.
The findings were reviewed and confirmed by the clinical supervisor.
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Plan of Correction
The primary counselor will photo copy patient photo ID and scan into the electronic record at the time of initial assessment. Clinical supervisor will ensure this is completed by utilizing the Clinical and Medical Chart audit to ensure this process has been completed. This will start on 6-19-14. |
715.9(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
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Observations
Based on the review of patient records, the facility failed to contact the previous narcotic treatment facility for the patient's treatment history in one of one patient records reviewed.
The findings included:
Sixteen patient records were reviewed during the on-site inspection. One patient record required contact with a prior narcotic treatment facility for the previous treatment history that was reported by the patient.
Patient record # 5 contained documentation the patient had received previous narcotic treatment services at another narcotic treatment program. The facility failed to document any attempt to obtain the patient's prior treatment history from the prior narcotic treatment facility.
The findings were reviewed and confirmed by the Facility Director.
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Plan of Correction
A training will be provided to all clinical staff on 715.9(c) on 6-19-14. Clinical Staff at the time of the initial assessment will complete releases for prior NTP participation to allow for treatment history to be released. The release, fax transmittal and information released will be scanned by the primary counselor into the electronic chart. Clinical supervisor will ensure this is completed by utilizing the Clinical and Medical Chart audit to ensure this process has been completed. This will start on 6-19-14. |
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
Based on the review of patient records, the facility failed to obtain an informed, voluntary, written consent prior to the administration of a narcotic agent for maintenance treatment in one of six patient records reviewed.
The findings included:
Sixteen patient records were reviewed during the on-site inspection. Six patient records were reviewed for the completion of an informed, voluntary written consent prior to the administration of a narcotic agent.
Patient # 5 was admitted into treatment on February 24, 2014, and discharged on March 18, 2014. The patient received their initial dose of methadone on February 24, 2014. There was no documentation of an informed, voluntary written consent prior to the administration of a narcotic agent in the patient record. This patient was a readmit to the program and the facility failed to have the patient sign a new consent to treat upon the readmission. The prior consent to treat was signed December 20, 2013.
The findings were reviewed and confirmed by the Facility Director.
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Plan of Correction
A training will be provided to all clinical staff on 715.12(1-5) on 6-19-14. Clinical Staff at the time of the initial assessment shall obtain an informed, voluntary, written consent to treatment. The admitting physician will ensure this is completed prior to ordering the initial dose. This will start on 6-19-14. Clinical supervisor will monitor via clinical and medical chart audits completed on all new admissions. |
715.16(c)(1)(i-iv) 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:
(1) A narcotic treatment program may permit a patient to reduce attendance at the narcotic treatment program for observation to three times weekly and receive no more than a 2-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 months.
(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.
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Observations
Based on the review of patient records, the facility granted take home privileges when the patient did not meet substantial progress in rehabilitation, specifically continued dose adjustments, in two of three patient records. Additionally, the facility granted take home privileges despite not having a patient demonstrate adherence to narcotic treatment program rules outside of a restricted setting in one of three patient records.
The findings included:
Sixteen patient records were reviewed during the on-site inspection. Three patient records were reviewed for no more than a 2-day take home supply of medication.
Patient # 4 was admitted on September 25, 2013, and discharged on April 14, 2014. The patient had been granted 4 take home doses per week (Wednesday, Thursday, Saturday and Sunday.) The patient record contained dose adjustments of a 10 mg increase on 3/31/2014 to a dose of 120 mg, a 10 mg increase on 3/24/2014, and a 5 mg increase on 3/7/2014. The patient record did not contain documentation of the narcotic treatment physician addressing the progress in rehabilitation, specifically regarding the dose adjustments.
Patient # 13 was admitted on February 12, 2014. The patient record contained an order for the granting of 4 take home doses per week on 6/3/2014. The patient record contained a dose adjustment of a 10 mg increase on 5/27/2014 to a dose of 110 mg. Additional dose increases occurred on 5/23/2014, 5/16/2014, 5/9/2014, 5/1/2014 and 4/25/2014. The patient record did not contain documentation of the narcotic treatment physician addressing the progress in rehabilitation, specifically regarding the dose adjustments.
Patient # 10 was admitted on January 30, 2014. The patient was incarcerated upon admission and had been released on May 28, 2014. The patient record contained an order for the granting of 4 take home doses per week on May 30, 2014. The patient record did not contain documentation of the narcotic treatment physician addressing the patient having demonstrated adherence to narcotic treatment program rules, specifically outside of a restricted setting.
The findings were reviewed and confirmed by the Facility Director.
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Plan of Correction
A training will be provided to all Discovery House physicians during the week of June 23, 2014 and June 27,2014 on granting takehome privileges. The training will focus on the 8 point evaluation and documenting findings in the takehome order. Program Director will monitor for compliance via quarterly chart reviews. This will take effect on 6/30/14. |
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 dose and schedule in five of sixteen patient records reviewed.
The findings included:
Sixteen patient records were reviewed during the on-site inspection. All patient records were reviewed for documentation of the patient's dose and schedule. Five patient records contained documentation of someone other than the narcotic treatment physician documenting the patient's dose and schedule, # 1, 2, 3, 10 and 11.
Patient # 1 signed an Involuntary Withdrawal Notification on December 13, 2013, at 6:15 a.m. The notification documented the patient's dose would be decreased 18 mgs. per day to begin on December 14, 2013. The notification was signed by the narcotic treatment physician on December 16, 2013. The record was reviewed for documentation of the narcotic treatment physician determining the dose change. The medical director wrote an order on December 13, 2013 at 8 a.m. stating the patient was to begin a 10 day taper. There was no documentation in the record prior to the notification being given to the patient that showed the narcotic treatment physician or the medical director determined the decrease of the patient's dose by 18 mgs. per day.
Patient # 2 signed an Involuntary Withdrawal Notification on February 14, 2014, at 12:05 p.m. The notification documented the patient's dose would be decreased 5 mgs. per day to begin on February 18, 2014. The notification was signed by the medical director on February 18, 2014. The record was reviewed for documentation of the medical director determining the dose change. The medical director wrote an order on February 18, 2014, at 8:47 a.m. stating the patient was to begin a 14 day taper. There was no documentation in the record prior to the notification being given to the patient that showed the medical director determined the decrease of the patient's dose 5 mgs. per day.
Patient # 3 signed an Involuntary Withdrawal Notification on December 23, 2013, at 6 a.m. The notification documented the patient's dose would be decreased 10 mgs. per day until January 2, 2014. The notification was signed by the narcotic treatment physician on December 23, 2013 at 9 a.m. The record was reviewed for documentation of the narcotic treatment physician determining the dose change. The narcotic treatment physician wrote an order on December 27, 2013, stating the patient's dose was to be decreased by 5 mgs. per day for 19 days. There was no documentation in the record prior to the notification being given to the patient that showed the narcotic treatment physician determined the decrease of the patient's dose 10 mgs. per day.
Patient record # 10 contained a pregnancy visit note on March 13, 2014, by the physician extender. The note stated the visit was due to the patient request for a dose assessment. The note stated the plan was to "continue Methadone 55 mgs." The record was reviewed for documentation of the narcotic treatment physician reviewing the dose assessment. There was no documentation in the record the narcotic treatment physician made the determination to continue the patient's current dose.
Patient record # 11 contained a pregnancy visit note by the physician extender. The note stated the plan was to "continue at 35 mgs." The record was reviewed for documentation of the narcotic treatment physician reviewing the dose assessment. There was no documentation in the record the narcotic treatment physician made the determination to continue the patient's current dose.
The findings were reviewed and confirmed by the Facility Director.
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Plan of Correction
Discovery House Physicians will create and will be the initial signer of all administrative withdrawal notifications. Once all required signatures are completed the Physician will complete the process by writting the order for the withdrawal which is required to be post 24 hours of the notification. This will take effect 6-19-14. Program Director will monitor via chart audits on a quarterly basis for those who were administratively withdrawaled from treatment.
The Physician extender will be provided a training regarding writing PDAP notes. The training will focus on dose assessments and that only the physician can determine if the patient can continue with current dose. This will take place on 6-19-14 and program Director and Clinical supervisor will monitor via quarterly chart audits.
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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 one patient records reviewed.
The findings included:
Sixteen patient records were reviewed during the on-site inspection. One patient record was reviewed for the required specific transfer of information to the receiving narcotic treatment program.
Patient # 6 was admitted on January 7, 2013, and discharged on May 19, 2014. The record contained documentation of the confirmation of the transfer of the patient to another narcotic treatment facility upon discharge. There was no documentation of the required specific transfer of information having been sent to the receiving narcotic treatment program.
The findings were reviewed and confirmed by the Facility Director.
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Plan of Correction
A training was held on 6/16/14 by the clinical supervisor and program director on the importance of sending all the required paperwork to the requesting facility. Effective 6/16/14, 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. The clinical supervisor will check to make sure all out going paperwork is correct and complete. The program director will review during quarterly chart audits to monitor compliance in this area. |
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 three patient records reviewed.
The findings included:
Sixteen patient records were reviewed during the on-site inspection. Three 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 # 3 was admitted on January 10, 2013, and was administratively discharged on January 15, 2014. The patient received an Involuntary Withdrawal Notification on December 23, 2013. The reason for termination listed on the termination notification letter was for non-compliance with treatment plan and goals. However, the discharge summary documented on January 16, 2014, indicated the patient was being terminated for not being drug free and for a financial balance. The facility failed to limit the reasons for termination from treatment to those permitted by the regulation.
The findings were reviewed and confirmed by the Facility Director.
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Plan of Correction
Effective immediately the Program Director will review all administrative withdrawal notifications to ensure the reason for the involuntary termination meets reasons allowed by regulation. Clinical staff will also be provided a training on documenting these reasons in the discharge summary. Program Director will monitor via chart audits on a quarterly basis for those who were administratively withdrawaled from treatment. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of patient records, the facility failed to obtain an informed and voluntary consent to release client information form and/or failed to ensure that consent to release client information forms did not exceed the restrictions imposed at 4 Pa. Code, Subsection 255.5(b)(1-5) in four of eight patient records reviewed.
The findings included:
4 Pa. Code 255.5 (b)(1-5) states:
(b) Restrictions. Information released to judges, probation or parole officers, insurance company health or hospital plan or governmental officials, under subsection (a)(1), (2), (4), (7) and (8), is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following:
(1) Whether the client is or is not in treatment.
(2) The prognosis of the client.
(3) The nature of the project.
(4) A brief description of the progress of the client.
(5) A short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.
Sixteen patient records were reviewed during the on-site inspection. Eight patient records were reviewed regarding release of client information forms. The facility failed to obtain an informed and voluntary consent to release client information form and/or failed to ensure that consent to release client information forms did not exceed the restrictions imposed at 4 Pa. Code, Subsection 255.5(b)(1-5) in patient records # 5, 7, 10 and 14.
Patient # 5 was admitted into treatment on February 24, 2014, and discharged on March 18, 2014. There were no current consents to release information documented in the patient record. This patient was a readmit to the program and the facility failed to have the patient sign new consents to release information to a legal entity and funding source. The prior consents to release information were signed December 20, 2013, and expired upon discharge.
Patient record # 7 contained a consent to release information to a funding source that permitted the release of laboratory results. These items exceeded 4 Pa. Code, Subsection 255.5(b)(1-5) for what is permitted to be released to a funding source.
Patient record # 10 contained a consent to release information to a legal entity that permitted the release of medication history and current dose level. These items exceeded 4 Pa. Code, Subsection 255.5(b)(1-5) for what is permitted to be released to a legal entity.
Patient record # 14 contained two consents to release information that identified the information to be released as "full disclosure." This a general statement of disclosure. Information to be disclosed must be specifically identified.
The findings were reviewed and confirmed by the Facility Director.
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Plan of Correction
A training will be provided to clinical staff on 6/24/14 on completing a release of information that is within standards. The training will also focus on the need to complete new releases for all readmissions. This will be effective 6/25/14. Clinical supervisor will ensure compliance by utilizing the Clinical and Medical Chart audit which is done within 30 days of all admissions. |