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 August 25-27, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center For Behavioral Health-Ha, Inc. 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 and a plan of correction is due on September 28, 2009.
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Plan of Correction
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715.6(a)(3)(i) LICENSURE Physician staffing
(a) A narcotic treatment program shall designate a medical director to assume responsibility for administering all medical services performed by the narcotic treatment program.
(3) The medical director 's responsibilities include the following:
(i) Supervision of narcotic treatment physicians.
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Observations
Based on the review of administrative documentation, the facility failed to include in the medical director's responsibilities, supervision of narcotic treatment physicians.
The findings include:
The policy and procedure manual was reviewed on August 26, 2009. The job description for the medical director was reviewed on August 27, 2009. The policy and procedure manual did not include documentation of anyone providing supervision to narcotic treatment physicians. The medical director's job description did not include supervision of the other narcotic treatment physicians as part of the medical director's responsibilities.
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Plan of Correction
The Program Director will ensure that the medical directors job description includes supervision of other narcotic treatment physicians as part of the medical directors responsibility. The policy manual will also include documentation of who is providing supervision to the narcotic treatment physicians. It is the sole responsibily of the Program Director to amend the policy to be in compliance with state regulations. |
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 failed to clearly show the physician made the face to face determination prior to the admission for maintenance treatment in 8 of 9 patient records.
The findings include:
Twenty seven patient records were reviewed August 25-27, 2009. Nine patient records were reviewed for admission documentation of the physician's face to face determination of current and one year history of dependency prior to the patient being admitted.
Patient record # 11 was admitted and dosed on 3-16-09. The physician signed his determination of current and one year dependency on 3-17-09.
Patient record # 12 was admitted and dosed on 7-27-09. The physician signed his determination of current and one year dependency on 7-28-09.
Patient record # 15 was admitted and dosed on 3-18-09. The physician signed his determination of current and one year dependency on 3-19-09.
Patient record # 16 was admitted and dosed on 8-11-09. The physician signed his determination of current and one year dependency on 8-12-09.
Patient record # 17 was admitted and dosed on 4-29-09. The physician signed his determination of current and one year dependency on 4-30-09.
Patient record # 19 was admitted and dosed on 2-2-09. The physician signed his determination of current and one year dependency on 2-4-09.
Patient record # 20 was admitted and dosed on 8-5-09. The physician signed his determination of current and one year dependency on 8-6-09.
Patient record # 23 was admitted and dosed on 1-27-09. The physician signed his determination of current and one year dependency on 1-28-09.
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Plan of Correction
The Program Director held an inservice for the physicians to ensure they document 1 year addiction in each patient file prior to admission. I will also review with the physician that the doucmentation of addiction in each patient history needs signed the same day as the documentation of addiction is completed. The Program Director will monitor each new admission to ensure the documentation of addiction is completed prior to admission to ensure compliance. |
715.10(d) LICENSURE Pregnant patients
(d) Within 3 months after termination of pregnancy, the narcotic treatment physician shall enter an evaluation of the patient 's treatment status into her record and state whether she should remain in comprehensive maintenance treatment or receive detoxification treatment.
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Observations
Based on the review of patient records, the narcotic treatment program failed to document, within three months after the termination of pregnancy, whether or not the patient should continue maintenance or receive detoxification treatment in 2 of 3 patient records.
The findings include:
Twenty seven patient records were reviewed August 25-27, 2009. An evaluation of the patient's treatment status within three months after termination of pregnancy was required in 2 patient records.
Patient # 10 delivered her baby 1-9-09. The Physician's Assistant (PA-C) and not the physician completed the evaluation of the patient's treatment status.
Patient # 11 had a pregnancy termination in April 2009. There was no documentation of an evaluation of the patient's treatment status at the time of the review.
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Plan of Correction
The Program Director will speak with the medical staff to ensure the physician is completing an evaluation of the patient's treatment within three months after termination of pregnancy. The Program Director will review the pregnancy log kept in the physicians office monthly to track pregnancies and check the pregnant patients charts 3 months after termanation of pregnancy to see the physician is documenting at the 3 month mark. |
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 administrative documentation, the facility failed to formulate a policy and procedure reflective of the standard.
The findings include:
The policy and procedure manual was reviewed on August 26, 2009. The policy and procedure addressing the frequency of drug-screening urinalysis did not specify at least monthly urine drug screenings are to be completed, but rather that they be performed 12 times per year "in accordance with most states" and leaves the patient with an option to return within 24 hours of not voiding upon request.
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Plan of Correction
The Program Director will submit for a revision in the policy. Revision submitted will read We shall complete an initial drug screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter. The Program Director will speak with function head for this revision at home office to get the revision completed to be in compliance with pennsylvania regulations. The program director will follow up till the revision is complete. |
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 the review of administrative documentation and patient records, the facility failed to follow their own policy for the initial exam and dose, as well as failing to have the physician document that he consulted with the person who performed the initial examination.
The findings include:
Twenty seven patient records were reviewed on August 25-27, 2009. Seven patient records were reviewed for admission physical exams. Two patient records documented the PA-C having completed the physical exam. There was no documentation by the physician of having consulted with the PA-C prior to determining the initial dose in patient records # 18 and 23..
The policy and procedure manual was reviewed on August 26, 2009. The policy and procedure manual stated that in Pennsylvania, the doctor performing the physical exam will determine the initial dose. The certified Physician's Assistant (PA-C) performs the admission physical exam and is not permitted by regulation to make an initial dose determination.
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Plan of Correction
The Program Director will meet with the Physician and Physician Assistant PA-C to ensure the physician is documenting his meeting with the Physician Assistant PA-C and going over the initial exam. The Physician Assistant will be instruted under no circumstances can the PA-C write for the initial dose or dose changes. This will be monitored by the program director by doing chart audits on new admissions and checking the documentation an seeing it is done according to the instructions given in our meeting. |
715.16(a)(5) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(5) A narcotic treatment program shall develop written policies and procedures relating to granting and rescinding take-home medication privileges.
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Observations
Based on a review of administrative documentation and staff interview, the facility failed to update the policies and procedures relating to granting take home medications according to the regulations.
The findings include:
The policy and procedure manual was reviewed on August 26, 2009. The policy and procedure manual contains verbiage allowing take home medication bottles to be granted according to previously allowed criteria guidelines.
Discussion with the director was conducted on August 26, 2009. The director reported the policy and procedure was not updated to reflect the requirements stated in the Licensing Alert issued in March 2009.
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Plan of Correction
Inservice completed by the clinical supervisor with the clinical associate to inform them of the take-home regulations we are following. Take-home priviliges will be given only by the regulation. The Clinical Supervisor and lead counselor will monitor take-home privilige request through checking the request for required time through supervision and will then submit request to the Medical Director for final approval. The Clinical Supervisor and Program Director will monitor also through chart audits. |
715.16(c)(3)(i-viii) 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:
(3) A narcotic treatment program may permit a patient to reduce attendance at the narcotic treatment program for observation to one time weekly and receive no more than a 6-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 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.
(v) A patient demonstrates no major behavioral problems.
(vi) A patient is employed, is actively seeking employment, attends school, is a homemaker or is considered unemployable for mental or physical reasons.
(vii) A patient is not known to have abused alcohol or other drugs within the previous year.
(viii) A patient is not known to have engaged in any criminal activity within the previous year.
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Observations
Based on a review of patient records on August 25-27, 2009, the facility failed to restrict 6 day take-home medication privileges to those who have been in treatment at least 3 years in 2 of 4 patient records.
The findings include:
Twenty seven patient records were reviewed on August 25-27, 2009. Four records were reviewed for compliance to granting take-home medication.
Patient record # 24 was admitted 11-7-2007. The patient was granted six take home bottle privileges in may of 2009, 18 months prior to having three years of continuous maintenance treatment.
Patient record # 25 was admitted 2-1-2008. The patient was granted six take home bottle privileges 8-6-2009, 18 months prior to having three years of continuous maintenance treatment.
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Plan of Correction
Inservice held on take home privilige regulations. The clinical supervisor and lead counselor will closly monitor request for clinical associates on take-home priviliges. This will also be monitored in supervision and by reviewing take-home request. Only when request meet the regulation will it be submitted to the medical director for approval. This will be monitored by the Program Director by keeping in close contact with Clinical Supervisor and Lead Counselor and doing case consults on patients who meet the regulation for take-home priviliges. |
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 4 of 4 patient records.
In addition, based on a physical plant tour and observation, the facility failed to restrict those other than patients from the dosing window and failed to conduct dosing in a manner that was not disruptive.
The findings include:
Twenty seven patient records were reviewed on August 25-27, 2009. Four patient records were reviewed for dose change orders. Patient records # 11, 15, 20 and 23 contained documentation by the PA-C to increase the patient's dosage.
On August 27, 2009, a physical plant tour of the dosing area was conducted at about 9:45 AM to !0:00 AM. During this time frame, it was observed there were 2 patients at one dosing window at the same time, a female went to the dosing window with a young pre-teen child and a group of 4 patients stood next to another dosing window loudly joking around with each other while another patient was dosing.
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Plan of Correction
The Physican Assistant has been instruced by the Program Director that inital dose and subsquent dose adjustments can only be made by the physician. The nursing associates have been instructed to only allow patient being medicated at the dosing window and there is never to be anyone other than the patient at the dosing window. This will be monitored by the Nurse Manager and The Program Director. |
715.17(c)(7) 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:
(7) Drug reactions and medication errors. A narcotic treatment program shall report any adverse drug reaction or medication error to a narcotic treatment physician immediately and initiate corrective action. The narcotic treatment program shall record the reaction or error in the drug administration record and the clinical chart, and shall inform each person who is authorized to administer medication or supervise self-medication of the reaction or error.
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Observations
Based on a review of administrative documentation, the facility failed to document that a medication error was reported to the narcotic treatment physician immediately.
The findings include:
The unusual incident report binder was reviewed on August 25, 2009. The documentation reviewed included an incident report dated 12/12/2008 for a medication error that occurred on 11/27/2008. A patient was double dosed with 130 milligrams of methadone. There was a notation on 12/3/2008 by the dosing nurse that the medical director and counselor was notified.
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Plan of Correction
The Program Director will conduct and inservice on incident reporting, the training will include who needs to be notified in case of unusual incident including medication or any other incident that could potentially indanger a patient. The Program Director will monitor by checking the incident reports when signing off and instruct associates to contact the program director/program manager immeadiately when an incident happens to insure all the proper persons have been informed. |
715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to document what materials were sent to the receiving narcotic treatment program in 1 of 3 patient records.
The findings include:
Twenty seven patient records were reviewed on August 25-27, 2009. Three patient records were reviewed for documentation of the material sent to the receiving facilities. There was no documentation of the material sent to the receiving narcotic treatment program in patient record # 22.
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Plan of Correction
The Program Director with the clinical supervisor will have an inservice to instruct all associates in proper documentation of a transfered patient making sure when transfer information is release to keep the transmittal sheet to prove it was sent and the form with the released information checked off put in the chart all associates will sign attendance sheet. Program Director and Clinical Supervisor will be responsible to audit discharge chart checking for the transmittal sheet, transfer form and what was transfered to be in the chart. |
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 administrative documentation, the facility failed to restrict the reasons for involuntary termination to those areas allowed by regulation.
The findings include:
The patient handbook was reviewed on August 26, 2009. Involuntary administrative termination was discussed on page 20. The reasons the facility could involuntarily terminate a patient included a statement "you violate the program rules" without being specific. On page 21 and 22 there was a discussion of what the program rules were. These rules exceeded what the regulations allow for involuntary termination, including having weapons on the property, wearing hats or sunglasses at the dosing window, loitering, and paying the fee on time
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Plan of Correction
The patient handbook have been revised and the offensive language has been removed. The old hand books have been removed. Program Director will be responsible to make sure new handbooks are given out and to remove the old ones. |
715.22(c) LICENSURE Patient grievance procedures
(c) Penalties may not be initiated prior to final resolution with the exception that penalties may be initiated against patients who have committed acts of physical violence or who have threatened to commit acts of physical violence in or around the narcotic treatment program premises.
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Observations
Based on a review of patient records and grievance documentation, the facility failed to not initiate penalties prior to the final resolution of the grievance and appeal process in one of one patient record.
The findings include:
Twenty seven patient records were reviewed on August 25-27, 2009. The grievance binder was reviewed on August 26, 2009. Patient # 6 was provided with written notice on 3-6-09 of intent to involuntarily detoxify in 24 hours. A physician order was documented for the detox to begin on 3-7-09. The patient's detox was begun on 3-7-09. The patient tried to request a grievance review on 3-6-09, but was told by the counselor to file it on Monday (3-9-09). The patient did present a written grievance on 3-9-09. He also requested a level 2 grievance review. On 3-11-09, the patient's involuntary detox was stopped for the level 2 process to commence. The patient's final determination was 3-21-09 which at that time, his detox was restarted.
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Plan of Correction
The Program Director will conduct an inservice in regards to the grievance procedure. When a patient files a grievance no action will be taken untill the grievance has been answered. All patients who wish to file a grievance will be given one immeadiately upon request. IF there is a second level request it too will be given immeadiately. The patient will remain in treatment with no change until there is a written answer given to the patient. The Program Director will be responsible to answer the grievance and will insure there is no change in treatment till the grievance issues are resolved. This will be done by keeping all parties involved in the process, the medical director, clinical supervisor, primary counselor and nursing associates. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on the review of patient records, the facility failed to document the results of annual reevaluations by the narcotic treatment physician three of three patient records.
The findings include:
Twenty seven patient records were reviewed on August 25-27, 2009. Annual reevaluations by the narcotic treatment physician were required in three patient records. The narcotic treatment program failed to document the results of the annual reevaluation by the narcotic treatment physician in patient records
# 5, 18 and 21.
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Plan of Correction
I will have a meeting with the Medical Direcor and Physician and explain the regulation on annual physical examinations and the Medical Director will be the only one to make this evaluation. Program Director to monitor by doing chart audits and also making the clinical supervisor and lead counselor aware of the documentation needed to be done so they can as well check during chart audits. |
715.23(b)(11) LICENSURE Patient records
(b) Each patient file shall include the following information:
(11) Counselor notes regarding patient progress and status.
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Observations
Based on review of patient records, the facility failed to provide the required information regarding the patient's progress and status in the clinical notes in 8 of 11 patient records.
The Data, Assessment, Plan (DAP) format was utilized. The "A" (assessment) failed to provide a clinical assessment of the patient's progress and the "P" (plan) focused on the date of the next session and not what the patient was to do based on the context of the treatment plan and the content of the work done in the counseling session in patient records # 2, 3, 10, 15, 17, 18, 22 and 24.
In addition, patient records # 15, 21 and 4 were abruptly discharged without any documentation by the counselor as to what occurred.
Patient records # 24 and 25 had documentation referring to the patients as "his" or "her" interchangeably.
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Plan of Correction
A training to be held by the clinical supervisor to address the documentation needed in the Data, Assessment, Plan (DAP) also better documentation on discharge patients to give a clear picture of why discharge occured and to use proper his or her when refering to patient. Clinical Supervisor will monitor through chart audits along with the lead counsler who also audits charts they will be informed to check as well. |
715.23(d)(2) 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.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Based on the review of patient records, the facility failed to document treatment plan goal updates in 4 of 6 patient records.
The findings include:
Twenty seven patient records were reviewed on August 25-27, 2009. Treatment plan updates were reviewed in six patient records. The narcotic treatment program did not document in the treatment plan updates the patient's progress in relationship to the stated goals in patient records # 6, 11, 19 and 24.
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Plan of Correction
The clinical supervisor is planning a training specifically in treatment planning, all clinical associates will attend. Clinical Supervisor will monitor through chart audits making sure treatment planning is done according to the training. |