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 3 through 5, 2013, 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)(4) 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:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on the review of patient records, the facility physician failed to document the basis for determining current opiate dependency in one of three patient records.
The findings include:
Fourteen patient records were reviewed on June 4 and 5, 2013. Three patient records were reviewed for the physician's documentation of the basis for determining current opiate dependency.
Patient # 11 was readmitted on April 17, 2013. The patient had been discharged on March 13, 2013, following a referral to inpatient detoxification. Record documentation included a call from the patient on March 28, 2013, noting the patient had completed inpatient detoxification. The physician documented the patient having prior treatment at the narcotic treatment program but did not reference the inpatient detoxification and rationale for one year dependency.
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Plan of Correction
A trainings will be provided by Program Director to Medical Director and Physician on documenting current opiate dependency. The training will take place on 6/21/13. The training will focus on documentation of prior treatment and 1 year history of addiction. Program Director to conduct quarterly audits of initial physical evaluation to ensure compliance. |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on the review of patient records, the facility failed to restrict the dose reviews to the narcotic treatment physician in one of seven patient records.
The findings include:
Fourteen patient records were reviewed on June 4 and 5, 2013. Seven patient records were reviewed for the required semi-annual dose review by the narcotic treatment physician. One patient record contained documentation of the Certified Registered Nurse Practitioner (CRNP) completing the semi-annual dose review, # 6.
Patient # 6 was admitted on May 19, 1999. An annual physical and dose review were completed on May 7, 2013 by the CRNP.
The documentation was confirmed by the facility director and clinical supervisor.
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Plan of Correction
Program Director provided a training to CRNP and PA that addressed dose reviews. They were instructed that only the Medical Director or Physician can complete this task. Medical Director to ensure compliance by reviewing all Dose reviews on a monthly basis to ensure compliance. The training was held on 6/20/13 and 6/21/13.
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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 failed to document the basis for determining continued take home privileges of 3 consecutive take home doses on an exception to 2-day take-home supply medication in one of two patient records.
The findings include:
Fourteen patient records were reviewed on June 4 and 5, 2013. Two patient records were reviewed for 2-day take-home supply of medication.
Patient # 10 was admitted on January 31, 2011. Due to the patient's isolated obligation and one time conflict with clinic attendance, the physician ordered the patient to receive a 3-day take-home supply of medication for 1 week on October 4, 2012. The patient continued to receive 3-day take-home supply of medication weekly until approved for routine 3-day take-home on February 7, 2013.
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Plan of Correction
A training was provided to the Medical Director and Physician on takehome privileges which focused on exceptions and time limited requests. Medical Director and Physician will ensure time limited exceptions that have been approved have expiring orders for when the exception is completed. Program Director to ensure compliance by reviewing exception orders on a quarterly basis. The training will be provided on 6/21/13. |
715.16(e) LICENSURE Take-home priveleges
(e) With an exception granted under subsection (d), a narcotic treatment program may not permit a patient to receive more than a 2-week take-home supply of medication.
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Observations
Based on the review of patient records, the facility failed to limit a patient to a 2-week take-home supply of medication in one of two patient records.
The findings include:
Fourteen patient records were reviewed on June 4 and 5, 2013. Two patient records were reviewed for 2-week take-home supply of medication.
Patient # 8 was admitted on November 10, 1998. An order for 2-week take-home supply has been continued since May 10, 2005, with a most recent review on May 28, 2013. Based on the dispensing history, on December 11, 2012, 14 take-home bottles were dispensed. On December 24, 2012, 14 more take-home bottles were dispensed as travel doses per the dispensing history. Facility records revealed that the patient attended a clinical session and provided a urine sample on December 11, 2012, and on January 8, 2013. According to a review of the facility records, 28 consecutive days of dispensing history were documented with take-home bottles and travel doses without an onsite dose identified.
The findings were reviewed and confirmed with the facility director and clinical supervisor.
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Plan of Correction
Program Director reviewed takehome exception criteria with all medical staff. The review focused on 2 week takehome status and return dates that fall on observed holidays to ensure no more than the two week status is provided. The program director will monitor during observed holidays to ensure complince. This review took place on 6/21/13. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on the review of patient records, the facility failed to provide individualized psychotherapy services in seven of seven records reviewed.
The findings include:
Fourteen patient records were reviewed on June 4 and 5, 2013. Seven patient records were reviewed for psychotherapy services during the patients' first 2 years of treatment, #1, 2, 3, 4, 9, 11 and 13. All records stated the patient will have 2.5 hours individual/group counseling per the treatment plan. Additionally, patient records # 2 and 3 did not have an average of 2.5 hours of psychotherapy services.
Patient # 2 was admitted on March 5, 2012, and discharged on April 24, 2013. The average psychotherapy hours were reviewed for the months of February, March and April 2013. The patient averaged 2.16 hours of psychotherapy for the three months reviewed.
Patient # 3 was admitted on January 13, 2012, and discharged on April 11, 2013. The average psychotherapy hours were reviewed for the months of January, February, and March 2013. The patient averaged 2.16 hours of psychotherapy for the three months reviewed.
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Plan of Correction
A training will be held by the clinical supervisor on 6/27/13 to ensure that each patient receives a minimum of 2.5 hours of psychotherapy per month. The training will also focus on ensuring indvidualized psychotherapy services are being provided as well as documented in the treatment plan. Counseling hours and individualized services will be reviewed with counselors during supervision to address deficiencies and create action plans. This will be monitored by the clinical supervisor and the Program director through chart audits to ensure compliance. This plan of action will take place 06/27/0213. |
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 record.
The findings include:
Fourteen patient records were reviewed on June 4 and 5, 2013. One patient record was reviewed for the required specific transfer information to the receiving narcotic treatment program.
Patient # 1 was admitted on November 26, 2012, and discharged on March 6, 2013. 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 information having been sent to the receiving narcotic treatment program. A consent to release information to the receiving narcotic treatment program did not include all of the required information to be disclosed.
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Plan of Correction
The Clinical Supervisor will provide a training to all clinical staff on what files are to be sent to facilitate a transfer and how to document once completed. The training will also focus on the released of information and need to include all items required to be sent. Documentation will be placed in the patient chart via scanning of the material sent and fax transmittal. The clinical supervisor and Program Director will monitor through monthly chart audits to ensure compliance. Training will take place on 6/27/13. |
715.21 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.
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Observations
Based on the review of patient records, the facility failed to initiate involuntary termination after all other efforts to retain the patient have failed in one of two patient records.
The findings include:
Fourteen patient records were reviewed on June 4 and 5, 2013. Two patient records were reviewed for involuntary terminations.
Patient # 4 was admitted January 27, 2012, and discharged on April 24, 2013. The annual case consult on January 6, 2013, stated the "patient has never had any behavioral issues at this clinic." The annual clinical evaluation documented on January 6, 2013, noted the patient had 6 negative drug screens. On December 25, 2012, the patient was given a take-home bottle. The facility failed to test the patient for his/her drug of choice until January 30, 2013. The patient had one positive opiate urine drug screen in thirteen results and one non-opiate positive in the four months prior to discharge. A "Treatment Agreement" was documented on July 16, 2012, for 60 days addressing daily dosing and ongoing "no shows" for clinical sessions. A "Treatment Agreement" was documented on October 26, 2012, for 60 days addressing daily dosing. Neither treatment agreement was renewed. The patient's treatment plan did not change to address issues identified. The discharge summary identified the reasons for termination as "no show for scheduled appointments, accrued a high balance, abusing opiates regularly and denying, and not dosing often".
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Plan of Correction
A training on involuntary terminations will be provide by the program director to all staff on 6/20/13 which will focus on reasons for involuntary terminations and how and where to document non compliance with treatment plan objectives. Program Director will review all potential involuntary terminations before being implemented to ensure compliance. This will take effect on 6/20/13.
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715..23(b)(1) LICENSURE Patient records
(b) Each patient file shall include the following information:
(1) A complete personal history.
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Observations
Based on the review of patient records, the facility failed to document a complete personal history in two of two records reviewed.
The findings include:
Fourteen patient records were reviewed on June 4 and 5, 2013. Two patient records were reviewed for a complete personal history. Patient records # 11 and 13 lacked detail in the personal histories by answering with one or two word answers and documenting a history that included only the past 30 days.
Patient # 11 was admitted on April 17, 2013. The facility failed to document family interrelationships history, a detailed employment/vocational history, detailed educational history, and sexual history.
Patient # 13 was admitted on January 28, 2013. The facility failed to document family interrelationships history, a detailed employment/vocational history, detailed educational history, and sexual history.
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Plan of Correction
A training will be Provided on 6/20/13 to clinical staff by the Clinical Supervisor on completing a complete personal history that includes detailed information. Clinical Supervisor to conduct individualized training during supervision and will conduct weekly chart audits starting 6/21/13 of assessments to ensure compliance. Program Director to conduct quarterly audits as well to ensure compliance. |
715.23(b)(2) LICENSURE Patient records
(b) Each patient file shall include the following information
(2) A complete drug and alcohol history.
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Observations
Based on a review of patient records, the facility failed to document the lengths and patterns related to the patient's progression of drug and alcohol use in one of two records reviewed.
The findings include:
Fourteen patient records were reviewed on June 4 and 5, 2013. Two patient records were reviewed for documentation of drug and alcohol history that included lengths and patterns related to the patient's progression of use. The facility failed to document the lengths and patterns related to the client's progression of use in patient record # 11.
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Plan of Correction
A training will be Provided on 6/20/13 to clinical staff by the Clinical Supervisor on documenting the lengths and patterns related to the patients progression of drug and alcohol use. Clinical Supervisor to conduct individualized training during supervision as well with new staff. Clinical Supervisor to review all intake assessments to ensure compliance starting 6/21/13. Program Director to conduct quarterly audits to ensure compliance. |
715.23(b)(14) LICENSURE Patient records
(b) Each patient file shall include the following information:
(14) Case consultation notes regarding the patient.
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Observations
Based on a review of patient records, the facility failed to document case consultations that included the attendees in eight of ten records reviewed.
The findings include:
Fourteen patient records were reviewed on June 4 and 5, 2013. Ten patient records were reviewed for the documentation of case consultations. In patient records # 1, 3, 4, 5, 6, 9, 10 and 13 there was no documentation regarding who attended the case consultation. The facility is using electronic signatures that provide dates of signatures. According to facility records, signatures to attest staff involvement signature were not signed on the date of the case consultation.
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Plan of Correction
The Clinical Supervisor will provide an in-service to review the standard of documenting the names and disciplines of those individuals attending the case consultation. The training will take place on 6/27/13. The clinical supervisor will complete consultation reviews one a monthly basis to ensure compliance starting 6/28/13. |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on a review of patient records, the facility failed to document psychosocial evaluations that provided a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation in two of two records reviewed.
The findings include:
Fourteen patient records were reviewed on June 4 and 5, 2013. Two of the records were reviewed for the content of the psychosocial evaluation. Patient records # 11 and 13 failed to include a psychosocial evaluation that included a composite picture of the client's problems and needs to be addressed in treatment, the client's assets and strengths, coping mechanisms, support systems, the negative factors that might inhibit treatment, and the counselor's impressions regarding the patient. The documentation included a repeat of the patient reported information and did not include an evaluation by the clinician for all required components.
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Plan of Correction
The Clinical Supervisor will provide a training on 6/20/13 as well as individual training during supervision on documenting psychosocial evaluations that provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the clients current situation. Clinical Supervisor to conduct weekly audits starting 6/21/13 on all psychosocial evaluations to ensure compliance. Program Director to also complete quarterly audits to ensure 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 a review of patient records, the facility failed to document discharge summaries that included all of the components in four of five records reviewed.
The findings include:
Fourteen patient records were reviewed on June 4 and 5, 2013. Five patient discharge records were reviewed. Patient records # 1, 2, 3, and 4 failed to include a discharge summary that included an individualized reason for treatment and/or a complete list of services offered.
Patient # 1 was admitted on November 26, 2012, and discharged on March 6, 2013. The facility failed to document an individualized reason for treatment. The summary stated the patient's reason for treatment was an "addiction to opiates, desire to maintain clean lifestyle" which is a requirement for admission.
Patient # 2 was admitted on March 5, 2012, and discharged on April 24, 2013. The facility failed to include medication as a service offered. A primary service of the facility is medication management.
Patient # 3 was admitted on January 13, 2012, and discharged on April 11, 2013. The facility failed to document an individualized reason for treatment. The summary stated the patient's reason for treatment was "patient has been using opiates regularly for several years." Opiate dependency is a requirement of admission. The facility also failed to include medication as a service offered. A primary service of the facility is medication management.
Patient # 4 was admitted on January 27, 2012, and discharged on April 24, 2013. The facility failed to document an individualized reason for treatment. The summary stated the patient's reason for treatment was an "opiate addiction, desire to be drug free" which is a requirement for admission.
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Plan of Correction
A training will be provided by the clinical supervisor on 6/27/13 which will review discharge summary components which include individualized reasons for treatment and a list of services provided. Clinical Supervisor will conduct audits on all discharge summaries to ensure compliance. This will take place on 6/28/13.
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