INITIAL COMMENTS
|
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 March 5-7, 2013 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 the facility. The following deficiencies were identified during this inspection.
|
Plan of Correction
|
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.
|
Observations
Based on a review of patient records, the facility failed to ensure that the narcotic treatment physician is determining the proper dosage level and schedule for a patient in five of twenty-two patient records.
The findings include:
Thirty-two patient records were reviewed on March 5-7, 2013. Twenty-two patient records were reviewed for medication orders, dosage and schedule determinations that were to be written and signed by the narcotic treatment physician. The facility did not document that the narcotic treatment physician determined the dosage level and schedules for a patient in patient records # 2, 12, 20, 21, and 25.
Patient # 2 was admitted on May 16, 2012. An order dated January 9, 2013 and signed by the CRNP stated that the patient was "returning from the hospital, split dosing combined, privileges revoked. See revocation". The patient was given a combined dose and take homes were revoked on January 9, 2013. The order was signed by the physician on January 10, 2013. There was no documentation of a verbal order. The patient received a dosage and schedule change prior to an order by the narcotic treatment physician.
Patient # 12 was admitted on June 23, 2011. An order dated June 8, 2012 and signed by a nurse stated "discontinue privileges as per counselor as per Dr." The patient's privileges were revoked on June 8, 2012. The order was signed by the physician on June 9, 2012. There was no documentation of a verbal order. The patient received a schedule change prior to an order signed by the narcotic treatment physician.
Patient # 20 was admitted on April 2, 2009. The patient was involuntarily discharged on December 27, 2012. The Notification of a Medically Supervised Withdrawal notice stated, "your dose will be decreased by 4 mgs per day until December 14, 2012." The notice was signed by the patient and director on November 23, 2012. There was no documentation of a physician's signature. The order signed by the physician on November 23, 2012 stated "MSW for non compliance". The patient's dose decrease started on November 23, 2012 as per dosing history. There was no documentation that the amount of the patient's dose decrease and schedule change had been ordered by the physician.
Patient # 21 was admitted on January 12, 2012. On October 25, 2012, the patient requested a voluntary detoxification. An order signed by the physician on October 25, 2012 did not document the dose decrease or the frequency of the decrease. The patient was decreased by 7 mgs daily as per the dosing history. The patient's take home privileges were also revoked on October 25, 2012. The was no physician's signature documented on the order. There was no documentation of a verbal order.
Patient # 25 was admitted on September 24, 2010 and was discharged on August 15, 2012.
The Notification of a Medically Supervised Withdrawal notice stated, "your dose will be decreased by 6 mgs per day until August 2, 2012". The notice was signed by the patient and counselor on August 2, 2012. There was no documentation of a physician's signature. The order signed by the physician on August 6, 2012 stated "MSW for non compliance". The patient's dose decrease started on August 6, 2012, as per dosing history. There was no documentation that the amount of the patient's dose decrease and schedule change had been ordered by the physician. The patient was to be involuntarily terminated from the program. The patient transferred to another treatment program prior to the completion of the medically supervised withdrawal. An order dated August 14, 2012 stated "hold at this dose pending transfer to treatment provider per their request. Ok' d with the Director". Order was signed by the physician on August 14, 2012. An order dated August 14, 2012 stated "cancel medically supervised withdrawal per clinical supervisor". The order was signed by the physician on August 14, 2012.
The Facility Director was interviewed on March 7, 2013 and confirmed the findings.
|
Plan of Correction
The Medical Director will write all orders for methadone changes. When in situations that MD is not physically present, a verbal order will be obtained from MD and written as such. All verbal orders will be signed by the prescribing physician within 24 hours. No medical orders will be written from non-medical associates at any time. Non-medical associates will consult with MD and document this consultation and the resulting decision in their notes and written as such. This will be immediate and on-going. Program Director will monitor for compliance. |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
|
Observations
Based on the review of patent records, the facility failed to document a psychosocial evaluation of the patient which included the patient's assets/strengths, support systems, coping mechanisms, negative factors and the counselor's conclusions/ impressions in six of ten patient records.
The findings include:
Thirty two patient records were reviewed on March 5-7, 2013. Ten patient records were reviewed for documentation of a psychosocial evaluation of the patient. The psychosocial evaluation of the patient did not include the patient's assets/strengths, support systems, coping mechanisms, negative factors or the counselor's conclusions/ impressions in patient records # 1, 5, 6, 7, 9 and 14.
Patient # 1 was admitted on October 22, 2012. The psychosocial evaluation, completed on October 29, 2012 contained historical and patient reported information and was not a clinical assessment of the patient's assets/strengths, support systems, coping mechanisms, negative factors or the counselor's conclusions/ impressions.
Patient # 5 was admitted on February 13, 2013. The psychosocial evaluation, completed on February 19, 2013 contained historical and patient reported information and was not a clinical assessment of the patient of the patient's assets/strengths, support systems, coping mechanisms, negative factors or the counselor's conclusions/ impressions.
Patient # 6 was admitted on July 26, 2012. The psychosocial evaluation, completed on July 30, 2012 contained historical and patient reported information and was not a clinical assessment of the patient of the patient's assets/strengths, support systems, coping mechanisms, negative factors or the counselor's conclusions/ impressions.
Patient # 7 was admitted on June 28, 2012. The psychosocial evaluation, completed on July 5, 2012 contained historical and patient reported information and was not a clinical assessment of the patient of the patient's assets/strengths, support systems, coping mechanisms, negative factors or the counselor's conclusions/ impressions.
Patient # 9 was admitted on June 8, 2012. The psychosocial evaluation, completed on June 14, 2012 contained historical and patient reported information and was not a clinical assessment of the patient of the patient's assets/strengths, support systems, coping mechanisms, negative factors or the counselor's conclusions/ impressions.
Patient # 14 was admitted on December 19, 2012. The psychosocial evaluation, completed on December 24, 2012 contained historical and patient reported information and was not a clinical assessment of the patient of the patient's assets/strengths, support systems, coping mechanisms, negative factors or the counselor's conclusions/ impressions.
The Facility Director and Clinical Supervisors were interviewed on March 7, 2013 and did not dispute the findings.
|
Plan of Correction
Pysc/soc will consist of clinical impressions, including all necessary areas, such as support systems, coping mechanisms, etc. This will be immediate and on-going. An in-service training will be held on 4/1/13 for our clinical team. Clinical Supervisor will monitor for compliance. |