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 October 20-22, 2008 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 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on November 19, 2008.
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Plan of Correction
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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 a review of sixteen patient records on 10-21-08 and 10-22-08, the facility failed to provide documentation that the previous narcotic treatment program was contacted for information in one of one patient record where required.
Finding:
The facility did not have a release of information signed nor did the facility provide documentation that they contacted the previous narcotic treatment program for the patient's treatment and dosage history in patient record #6.
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Plan of Correction
Discovery House will obtain a release of information for previous providers and contact those providers for information for every patient who meets the criteria for admission to our program. Clinical Supervisor will monitor for compliance. This will be immediate and ongoing. |
715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
Based on a review of sixteen patient records on 10-21-08 and 10-22-08, the facility failed to provide an informed consent to release information form in four of twelve patient records where required.
Finding:
The facility failed to provide informed consent to release information forms in patient records. Informed consent to release information forms were not documented in patient records # 3, 5, 6 and 13. Standardized language on the consent to release information forms indicate that client identifying information would be "obtained from" an entity as well as "released to" that entity. This language is confusing and does not amount to an informed consent to release information. In addition, patient record #13 included another patients completed physical examination.
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Plan of Correction
Discovery House associates will utilize releases for one way only communication, and refrain from marking multiple options on the release form. Clinical Supervisor will hold an in-service training on releases on 11/13/08. Clinical Supervisor will monitor for compliance. Estimated date of completion: 11/30/08. Clinical Supervisor will also monitor hard-copy files to ensure integrity of files for information related to that patient. This will be immediate and ongoing. |
715.16(a)(4) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(4) A narcotic treatment physician may rescind take-home medication privileges.
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Observations
Based on a review of sixteen patient records on 10-21-08 and 10-22-08, the facility failed to provide documentation that the physician made the decision to rescind the take home privileges in one of one patient records where required.
Finding:
The facility failed to provide a physician signature on the medication order rescinding take home privileges for patient record # 16.
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Plan of Correction
The Medical Director will sign all orders for revocation of take home privileges for all patients on an immediate and ongoing basis. Program Director will monitor for compliance. |
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 a review of sixteen patient records on 10-21-08 and 10-22-08, the facility failed to provide documentation that the physician is making the decision to start a medically supervised withdrawal and decrease in the dosage in one of one patient record where required.
Finding:
The facility did not document the decision to start a medically supervised withdrawal and decrease in dosage for patient record # 13.
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Plan of Correction
Documentation will be made for every instance that a medically supervised withdrawal is necessary. This documentation will include reason for the withdrawal and decrease in dose information. Clinical Supervisor will monitor for compliance. This will be immediate and ongoing. |
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 a review of sixteen patient records on 10-21-08 and 10-22-08, the facility failed to provide involuntary discharges consistent with the regulations in three of five patient records where required.
Finding:
Patients # 13, 14, and 16, were discharged for financial reasons.
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Plan of Correction
A patient's treatment plan will include financial responsibility as a goal and any issues, whether financial or any other, will be well documented prior to a discharge being started. Clinical Supervisor will monitor for compliance. This will be immediate and ongoing. |
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 a review of sixteen patient records on 10-21-08 and 10-22-08, the facility failed to include a re-evaluation by the physician in the annual physical examination in one of four patient records where required.
Finding:
The facility physician did not document a re-evaluation in the annual physical examination in patient record # 8.
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Plan of Correction
The Medical Director will document a re-evaluation with every annual physical exam done on an immediate and ongoing basis. Program Director will monitor for compliance. |
715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
Based on a review of the project' policy and procedures on October 20, 2008, the facility failed to provide a complete policy and procedure for reporting unusual incidents.
Finding:
The facility failed to include references to incidents # 1, 2, 4, 6, and 7 in the policy and procedure for reporting unusual incidents.
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Plan of Correction
Discovery House's home office has re-written this to include all necessary incidents. Program Director will monitor for compliance. Estimated time of completion: 12/15/2008 |