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 and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on September 1, 2 & 3, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House - NC, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and a plan of correction is due on October 4, 2009.
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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 a review of patient records and staff interviews, the facility failed to document that the physician made determinations of patient addiction in two of eleven patient records.
The findings include:
Twenty two patient records were reviewed September 1-3, 2009, eleven were reviewed for the physician's face-to-face determination of addiction. The facility failed to provide documentation that the physician performed face-to-face determinations of addiction for all patients assessed for admission to treatment. Patient # 10 was admitted April 9, 2009; the patient record indicated that the patient determination of addiction was documented by the CRNP on April 29, 2009. Patient # 11 was admitted into the program April 9, 2009; the determination of addiction was completed by the CRNP.
Only the physician may document determinations of addiction.
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Plan of Correction
The Program Director will hold an inservice training with the Medical Director and the CRNP to ensure that all determinations of addiction are made only by the Narcotic Treatment Physician. The training will be completed within 14 days. The Program Director will monitor each new admission to fulfill compliance with the regulation. |
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
Based on a review of patient records and a staff interview, the facility failed to ensure that the patient was initially dosed following the completion of a drug-screen urinalysis in one of eleven patient records.
The findings included:
Twenty two patients were reviewed September 1 - 3, 2009, eleven were reviewed for drug screen urinalysis results prior to a patient's initial dose. Facility documentation identified that patient # 5 was dosed prior to the facility's receipt of urinalysis results. Patient # 5 was admitted into treatment on April 28, 2009. A review of patient # 5's record revealed that the patient had received a dose of 20 mg on April 28, 2009, the same date that the patient had submitted a urine specimen for a drug-screen urinalysis. Discussion with the facility director confirmed that the patient had been dosed before the results of the urinalysis had been received.
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Plan of Correction
The Program Director will hold an inservice training to review and reinforce the requirment to aquire a "completed" initial drug-screening urinalysis for each prospective patient prior to admission. This training will include the entire medical staff and be completed within 14 days. The program Director will monitor each new admission 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 a review of patient records and staff interview, the facility failed to document dosage reviews that were consistent with the regulations in two of nine patient records.
The findings include:
Twenty two patients records were reviewed September 1 -3, 2009, nine were reviewed for documentation that identified that the physician had dosage reviews at least twice a year. Two patient records failed to include documentation of the physician's review of patient dosages. Patient records # 19 and 21 included documentation that the CRNP had reviewed patient dosages and determined them to be therapeutic. Only the physician may make these determinations.
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Plan of Correction
The citation has been addressed with the Medical Director and the CRNP. The medical Director will complete all dose reviews and document his determination of the patient's therapeutic dosage. This will be immediate and ongoing. Program Director will monitor for full compliance throughout the year. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records, the facility failed to ensure that the narcotic treatment physician determined the proper dosage level for a patient in one of ten records.
The records include:
Twenty two records were reviewed September 1-3, 2009, ten were reviewed for content that identified that the physician was determining the proper dosage for a patient. In patient record # 10 the CRNP ordered a 30 mg dose on April 10, 2009. There was no documentation that the physician made the determination.
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Plan of Correction
The Program Director held a training with the Medical Director to ensure the physician documents his rational for granting takehome privledges. The Program Director will be responsible for oversight. |
715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
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Observations
Based on a review of patient records,the facility failed to document the physician's rationale for providing take-home medications in two of nine records.
Twenty two patient records were reviewed September 1-3, 2009, nine were reviewed for content related to take-home medication determinations made by the physician. The facility failed to document the physician's rationale for providing take home medications. In patient records #18 and #20 the physician documented he agreed with the recommendation of staff but did not provide the rationale for the provision of take home medications.
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Plan of Correction
The Program Director will hold an inservice training with the Medical Director and CRNP addressing the regulation. The training will be completed within 14 days. The physician only will determine the patient's initial dose. The Program Director will be responsible to monitor for compliance. |
715.16(b)(1-8) LICENSURE Take-home privileges
(b) The narcotic treatment physician shall consider the following in determining whether, in exercising reasonable clinical judgment, a patient is responsible in handling narcotic drugs:
(1) Absence of recent abuse of drugs (narcotic or non-narcotic), including alcohol.
(2) Regular narcotic treatment program attendance.
(3) Absence of serious behavioral problems at the narcotic treatment program.
(4) Absence of known recent criminal activity.
(5) Stability of the patient 's home environment and social relationships.
(6) Length of time in comprehensive maintenance treatment.
(7) Assurance that take-home medication can be safely stored within the patient 's home.
(8) Whether the rehabilitative benefit to the patient derived from decreasing the frequency of attendance outweighs the potential risks of drug diversion.
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Observations
Based on a review of patient records and staff interview, the facility failed to document the facility had followed the eight point criteria for determining take-home medication in one of six patient records.
The findings include:
Twenty two patient records were reviewed September 1-3, 2009, six were reviewed to determine compliance with the utilization of the eight point criteria for the determination of take-home medication. The facility maintained a form that was utilized to review the eight point criteria necessary when considering take-home privileges for each patient. The form was completed by staff before submission to the physician. The facility failed to document patient # 19's current problems in his home environment on this form. The patient was granted take-home medications without consideration to the status of his current home situation.
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Plan of Correction
The Clinical supervisor will provide a training to the clinical staff on the 8 point evaluation which will include documentation of all pertinant information relevant to the 8 points. Clinical Supervisor will also address this individually with clinical staff as needed to ensure compliance. This will take place within 30 days and Clinical Supervisor will be responsible. |
715.16(c)(2)(i-iv) LICENSURE Take-home previliges
(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:
(2) A narcotic treatment program may permit a patient to reduce attendance at the narcotic treatment program for observation to two times weekly and receive no more than a 3-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 2 years.
(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 a review of patient records, the facility failed to consider the regulations in the determination of 3-day take-home medications in one of six patient records.
The findings include:
Twenty two patient records were reviewed September 1-3, 2009, six were reviewed for take-home medication determination. A review of patient record # 19 revealed that the patient had been in treatment for one year and had started to receive 3-day take-home medication privileges on September 3, 2009. In accordance with the regulations a patient is required to be in treatment for two years before they can be considered for three-day take-home status.
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Plan of Correction
An inservice training will be held by the Program Director regarding the current take home privilege guidelines and regulations. The training will be completed within 14 days. The Clinical Supervisor will monitor requests for take home privileges to ensure compliance with the regulations. Program Director will be responsible for oversight. |
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, the facility failed to restrict the determination of a patient's dose to the physician in three of eleven patient records.
Further the facility failed to follow physician dosing orders in one patient record.
The findings include:
Twenty two patient records were reviewed on September 1-3, 2009. Three patient records were reviewed for dose change orders. Patient records # 1, 8, and 10 contained documentation by the CRNP to determine the patient's dosage.
Patient record #1 contained documentation of dose determination by the CRNP on July 29, 2009.
Patient record #8 contained documentation of dose determination by the CRNP on July 8, 2009, July 15, 2009, July 22, 2009 and August 5, 2009.
Patient record # 10 contained documentation of dose determination by the CRNP on April 22, 2009.
Additionally the physician ordered a medication induction of 30 mg for patient #3 on January 12, 2009 and further ordered a 5 mg incremental increase for the following day. A review of the patient record included dosage information that revealed the patient was not dosed on January 12, 2009. The patient's first dose occurred January 13, 2009 at which time the patient was given 35 mg. The facility failed to follow physician's orders for the medication administration of patient #3.
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Plan of Correction
The Program Director will hold a training for medical staff on policy and procedures as it relates to 715.16(c)(1)(i-vi). The training will focus on how the Narcotic Treatment Physician shall determine the patient's initial and subsequent dose and schedule. This will take place in 30 days and Program Director will be responsible. |
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 a review of patient records, the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment in 7 of 11 records.
The findings include:
Twenty two patient records were reviewed September 1-3, 2009,11 were reviewed for psychotherapy content.
Patient # 1 received 1.5 hours of psychotherapy in July 2009 and 1 hour in August 2009 for an average of 1.25 hours.
Patient # 2 received 1.25 hours of psychotherapy in July 2009 and 2.5 hours in August 2009 for an average of 1.86 hours.
Patient # 7 received .5 hours of psychotherapy in June 2009, 1.75 hours in July 2009 and 1.5 hours in August 2009 for an average of 1.25 hours.
Patient # 8 received 0 hours of psychotherapy in July 2009 and 2.5 hours in August 2009 for an average of 1.25 hours. Further, patient #8 was admitted into treatment June 30, 2009; the patient record did not document any counseling for patient # 8 until August 13, 2009.
Patient # 10 entered treatment April 10, 2009; the first documented counseling session occurred May 20, 2009.
Patient #19 was admitted May 15, 2009; the first documented counseling session occurred June 11, 2009.
Patient #20 received .5 hours of psychotherapy in June 2009, 2.5 hours in July 2009 and 1.5 hours in August 2009 for an average of 1.5 hours.
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Plan of Correction
The Clinical Supervisor will conduct weekly reviews of required and provided direct service hours. Compliance will be addressed during clinical supervision and action plans will be required when counselors do not provide ample service hours. Timeframe to implement is immediate. The program Director and Clinical Supervisor will be responsible for oversight. |
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 a review of patient records, policy and procedure manual and other facility documentation, the facility's documented reasons for patient termination exceeded the regulations.
The findings include:
The patient handbook stipulated reasons for involuntary termination to include violation of program rules. Also, missed appointments or repeatedly rescheduled appointments were identified as a potential reason for termination as was the failure to provide urine samples. These identified reasons for involuntary terminations exceeded the regulations.
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Plan of Correction
The Program Director will remove any existing language in the patient handbook that identifies reasons for involuntary terminations that exceed the regulations. The timeframe for removal will be immediate. New patient handbook will be in place within 60 days. |
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 in two of eleven patient records.
The findings include:
Twenty two patient records were reviewed September 1-3 2009, eleven were reviewed for psychosocial evaluation content.
Patient #1 entered treatment July 22, 2009; at the time of the review there was no completed psychosocial evaluation in the patient record.
Patient #8 entered treatment June 30 2009; at the time of the review there was a psychosocial evaluation that consisted of only of client report and no clinical assessment.
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Plan of Correction
An inservice training will be provided by the Clinical Supervisor addressing the requirment for a documented psychosocial evaluation in each patient record. The training will be completed by 10/31/2009. The Clinical Supervisor will also address this issue during individual supervision. The Program Director will monitor compliance through the utilization of chart audits and the services provided report. |
715.23(d) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to provide preliminary treatment plans at admission in five of twelve patient records.
The findings include:
Twenty two patient records were reviewed September 1-3, 2009. The facility failed to provide preliminary treatment plans at the time of admission in five of twelve records.
Patient #1 entered treatment July 22, 2009, the preliminary treatment plan was completed August 14, 2009.
Patient #2 entered treatment June 26, 2009., the preliminary treatment plan was completed July 17, 2009.
Patient #3 entered treatment January 13, 2009, the preliminary treatment plan was completed January 23, 2009.
Patient #10 entered treatment April 10, 2009, the preliminary treatment plan was completed on May 18, 2009.
Patient #12 entered treatment on June 12, 2009, the preliminary treatment plan was completed on July 1, 2009.
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Plan of Correction
The Clinical Supervisor will provide an inservice training on the preparation of initial treatment plans that will focus on outlining realistic short and long term goals and timeframes to be completed. Clinical Supervisor will review initial treatment plans at admission and during individual supervision to monitor for compliance. The inservice training will be completed within 30 days. |
715.23(d)(1) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(1) The treatment plan shall identify the behavioral tasks a patient shall perform to complete each short-term goal.
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Observations
Based on a review of patient records, the facility failed to document support services in eleven of eleven records.
The findings include:
The facility failed to document support services in treatment plans for patients #1, 2, 3, 5, 6, 7, 8, 9, 10, 11 and 12.
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Plan of Correction
An inservice training will be held by the Clinical Supervisor for all clinical staff on identifying and documenting behavioral tasks a patient shall perform to complete each short term goal. Clinical Supervisor will monitor for compliance before approving and signing off on treatment plans. This will take place within 30 days. |