D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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HARRISBURG COMPREHENSIVE TREATMENT CENTER
3601 PROGRESS AVENUE
HARRISBURG, PA 17110

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Survey conducted on 11/17/2010

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection conducted on November 15 through November 17, 2010 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 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on December 18, 2010.	Plan of Correction
709.22(e)(2) LICENSURE Governing Body 709.22. Governing body. (e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to: (2) A financial statement of income and expenses.
Observations Based on a review of the 2009 annual report during the onsite licensing inspection of November 15-17, 2010 and an interview with the facility director the facility failed to document a financial statement of income and expenses in the body of the report. The findings include: The annual report was reviewed during the licensing inspection. No financial statement of income and expenses was documented. The facility director confirmed that this was not included in the annual report.	Plan of Correction 709.22(e)(2) Additional information for the Annual Report has been added included are the Clinic Vitals signs which includes our census, private AR, 3rd Party AR, bad debt, Sales, gross payroll. We have also included our clinic expenses in a breakdown of Payroll, Payroll Taxes, Facility Costs, Office Cost, Payroll benefits, Lab fees, Professional Services, Bad Debt, Medical Supplies, Depreciation & Amortization. Also included For 12 Months ending December 31, 2009 Revenue Total Revenue figure and Total Expenses will be added. This will be kept current by the Program Director.
709.25(a) LICENSURE Fiscal Management 709.25. Fiscal management. (a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
Observations Based on the review of facility financial documents during the onsite licensing inspection, the facility failed to document an audit for the year ended 12/31/2009. The findings included: Division staff reviewed the documentation presented when the annual audit was requested. The documentation presented by the facility director consisted of a financial statement for the year ended 12/31/09. The letter from the accountant stated "...a review consists of inquiries of group personnel and analytical procedures applied to financial data. It is substantially less in scope than an audit in accordance with auditing standards". The documentation presented failed to meet the requirement for the annual financial audit. This is a repeat citation from the licensing inspection conducted on December 21-23, 2009.	Plan of Correction Discovery House will conduct an audit for FY 2010. We will submit a 2009 compellation review and an engagement letter for 2010. Director will monitor for compliance.
709.28(c) LICENSURE Confidentiality 709.28. Confidentiality. (c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
Observations Based on the review of client records during the annual licensing inspection and interviews with facility staff, the facility failed to ensure that informed and voluntary consents were completed prior to each disclosure of information contained in the client records. The findings included: Seventeen patient records were reviewed during the annual licensing inspection. Each record was required to have a signed consent for each disclosure of information from each patient record. Two of two patient records required to have a consent for a third party payer failed to document a consent prior to releasing information, specifically patient records 4 and 7. The findings are as follows: Documentation in patient record # 4 demonstrated that the facility released information to a third party payer source without obtaining a written consent to release information from the patient. The patient was admitted on 6/28/2010. Documentation in patient record # 7 demonstrated that the facility released information to a third party payer source without obtaining a written consent to release information from the patient. The patient was admitted on 6/28/2010. This is a repeat citation from the licensing inspection conducted on December 21-23, 2009.	Plan of Correction The Program Director held training on 12/09/10 regarding the importance of having a valid consent to release information from the patient record. Effective 12/09/10 there will be a check list for all new admissions to make sure there that the consent is signed prior to admission. The clinical supervisor will monitor all new admission releases via monitoring the new checklist to ensure all releases are completed. The program director will do sporadic checks to ensure compliance. Overall the Program Director and Clinical Supervisor will be responsible.
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 the review of patient records, the facility failed to demonstrate the physician made the determination of the patient's dose in sixteen of seventeen patient records. The findings include: Seventeen patient records were reviewed November 16-17, 2010. Sixteen patient records were reviewed for physician's documentation of the patient's initial and subsequent dose and schedule. A review of patient records revealed that the physician used a numbered list of standard orders utilized during the induction phase of treatment and documented the orders in patient's initial physical. Patient # 1 was admitted March 16, 2010. A standard order was used to order the initial dose with written instruction that permitted dose increases at the discretion of the nursing staff over the next week of the induction phase. The order written in the physical stated: Client record # 6 - Specified standard dosing order " #6. During the first 30 days of treatment the Certified Registered Nurse Practitioner (CRNP), Physician Assistant (PA), or nurse shall adjust the dose of methadone upward by 5 mg for stabilization of withdrawal symptoms. The CRNP, PA or nurse must wait 5 days after adjusting the dose to adjust the dose upward again. They may not exceed the withdrawal symptoms after the first 30 days." contact the physician. Client record #7 - Specified dosing order "# 7. The CRNP, PA, or nurse should adjust the doses based on the patient's withdrawal symptoms (to) include sweats, chills, nausea, vomiting, goose bumps, runny nose, tearing eyes, yawning, etc. The CRNP, PA or nurse may use the COWS to document the patient withdrawal. If the patient complains of withdrawal symptoms 24 hours after the last dose contact the physician." Patient # 2 was admitted May 4, 2010. A standard order was used to order the initial dose and then the increases were left to the discretion of the nursing staff over the next week of the induction phase. The dosing order written in the physical stated, " #6. During the first 30 days of treatment after the Certified Registered Nurse Practitioner (CRNP), Physician Assistant (PA), or nurse shall adjust the dose of methadone upward by 5 mg for stabilization of withdrawal symptoms. The CRNP, PA or nurse must wait 5 days after adjusting the dose to adjust the dose upward again. They may not exceed the withdrawal symptoms after the first 30 days, contact the physician. #7 The CRNP, PA, or nurse should adjust the doses based on the patient's withdrawal symptoms include sweats, chills, nausea, vomiting, goose bumps, runny nose, tearing eyes, yawning, etc. The CRNP, PA or nurse may use the COWS to document the patient withdrawal. If the patient complains of withdrawal symptoms 24 hours after the last dose contact the physician." Patient # 3 was admitted August 30, 2010. A standard order was used to order the initial dose and then the increases were left to the discretion of the nursing staff over the next week of the induction phase. The order written in the physical stated, " #6. During the first 30 days of treatment after the Certified Registered Nurse Practitioner (CRNP), Physician Assistant (PA), or nurse shall adjust the dose of methadone upward by 5 mg for stabilization of withdrawal symptoms. The CRNP, PA or nurse must wait 5 days after adjusting the dose to adjust the dose upward again. They may not exceed the withdrawal symptoms after the first 30 days, contact the physician. #7 The CRNP, PA, or nurse should adjust the doses based on the patient's withdrawal symptoms include sweats, chills, nausea, vomiting, goose bumps, runny nose, tearing eyes, yawning, etc. The CRNP, PA or nurse may use the COWS to document the patient withdrawal. If the patient complains of withdrawal symptoms 24 hours after the last dose contact the physician." Patient # 4 was admitted June 28, 2010. A standard order was used to order the initial dose and then the increases were left to the discretion of the nursing staff over the next week of the induction phase. The standard dosing order written in the physical stated, " #6. During the first 30 days of treatment after the Certified Registered Nurse Practitioner (CRNP), Physician Assistant (PA), or nurse shall adjust the dose of methadone upward by 5 mg for stabilization of withdrawal symptoms. The CRNP, PA or nurse must wait 5 days after adjusting the dose to adjust the dose upward again. They may not exceed the withdrawal symptoms after the first 30 days, contact the physician. #7 The CRNP, PA, or nurse should adjust the doses based on the patient's withdrawal symptoms include sweats, chills, nausea, vomiting, goose bumps, runny nose, tearing eyes, yawning, etc. The CRNP, PA or nurse may use the COWS to document the patient withdrawal. If the patient complains of withdrawal symptoms 24 hours after the last dose contact the physician." Patient # 5 was admitted November 3, 2010. A standard order was used to order the initial dose and then the increases were left to the discretion of the nursing staff over the next week of the induction phase. The order written in the physical stated, " #6. During the first 30 days of treatment after the Certified Registered Nurse Practitioner (CRNP), Physician Assistant (PA), or nurse shall adjust the dose of methadone upward by 5 mg for stabilization of withdrawal symptoms. The CRNP, PA or nurse must wait 5 days after adjusting the dose to adjust the dose upward again. They may not exceed the withdrawal symptoms after the first 30 days, contact the physician. #7 The CRNP, PA, or nurse should adjust the doses based on the patient's withdrawal symptoms include sweats, chills, nausea, vomiting, goose bumps, runny nose, tearing eyes, yawning, etc. The CRNP, PA or nurse may use the COWS to document the patient withdrawal. If the patient complains of withdrawal symptoms 24 hours after the last dose contact the physician." Patient # 6 was admitted April 9, 2010. A standard order was used to order the initial dose and then the increases were left to the discretion of the nursing staff over the next week of the induction phase. The standard dosing order written in the physical stated, " #6. During the first 30 days of treatment after the Certified Registered Nurse Practitioner (CRNP), Physician Assistant (PA), or nurse shall adjust the dose of methadone upward by 5 mg for stabilization of withdrawal symptoms. The CRNP, PA or nurse must wait 5 days after adjusting the dose to adjust the dose upward again. They may not exceed the withdrawal symptoms after the first 30 days, contact the physician. #7 The CRNP, PA, or nurse should adjust the doses based on the patient's withdrawal symptoms include sweats, chills, nausea, vomiting, goose bumps, runny nose, tearing eyes, yawning, etc. The CRNP, PA or nurse may use the COWS to document the patient withdrawal. If the patient complains of withdrawal symptoms 24 hours after the last dose contact the physician." Patient # 7 was admitted June 28, 2010. A standard order was used to order the initial dose and then the increases were left to the discretion of the nursing staff over the next week of the induction phase. The standard dosing order written in the physical stated, " #6. During the first 30 days of treatment after the Certified Registered Nurse Practitioner (CRNP), Physician Assistant (PA), or nurse shall adjust the dose of methadone upward by 5 mg for stabilization of withdrawal symptoms. The CRNP, PA or nurse must wait 5 days after adjusting the dose to adjust the dose upward again. They may not exceed the withdrawal symptoms after the first 30 days, contact the physician. #7 The CRNP, PA, or nurse should adjust the doses based on the patient's withdrawal symptoms include sweats, chills, nausea, vomiting, goose bumps, runny nose, tearing eyes, yawning, etc. The CRNP, PA or nurse may use the COWS to document the patient withdrawal. If the patient complains of withdrawal symptoms 24 hours after the last dose contact the physician." Patient # 8 was admitted July 12, 2010. A standard order was used to order the initial dose and then the increases were left to the discretion of the nursing staff over the next week of the induction phase. The standard dosing order written in the physical stated, " #6. During the first 30 days of treatment after the Certified Registered Nurse Practitioner (CRNP), Physician Assistant (PA), or nurse shall adjust the dose of methadone upward by 5 mg for stabilization of withdrawal symptoms. The CRNP, PA or nurse must wait 5 days after adjusting the dose to adjust the dose upward again. They may not exceed the withdrawal symptoms after the first 30 days, contact the physician. #7 The CRNP, PA, or nurse should adjust the doses based on the patient's withdrawal symptoms include sweats, chills, nausea, vomiting, goose bumps, runny nose, tearing eyes, yawning, etc. The CRNP, PA or nurse may use the COWS to document the patient withdrawal. If the patient complains of withdrawal symptoms 24 hours after the last dose contact the physician." Patient # 9 was admitted August 10, 2010. A standard order was used to order the initial dose and then the increases were left to the discretion of the nursing staff over the next week of the induction phase. The standard dosing order written in the physical stated, " #6. During the first 30 days of treatment after the Certified Registered Nurse Practitioner (CRNP), Physician Assistant (PA), or nurse shall adjust the dose of methadone upward by 5 mg for stabilization of withdrawal symptoms. The CRNP, PA or nurse must wait 5 days after adjusting the dose to adjust the dose upward again. They may not exceed the withdrawal symptoms after the first 30 days, contact the physician. #7 The CRNP, PA, or nurse should adjust the doses based on the patient's withdrawal symptoms include sweats, chills, nausea, vomiting, goose bumps, runny nose, tearing eyes, yawning, etc. The CRNP, PA or nurse may use the COWS to document the patient withdrawal. If the patient complains of withdrawal symptoms 24 hours after the last dose contact the physician." Patient # 10 was admitted May 3, 2010. A standard order was used to order the initial dose and then the increases were left to the discretion of the nursing staff over the next week of the induction phase. The standard dosing order written in the physical stated, " #6. During the first 30 days of treatment after the Certified Registered Nurse Practitioner (CRNP), Physician Assistant (PA), or nurse shall adjust the dose of methadone upward by 5 mg for stabilization of withdrawal symptoms. The CRNP, PA or nurse must wait 5 days after adjusting the dose to adjust the dose upward again. They may not exceed the withdrawal symptoms after the first 30 days, contact the physician. #7 The CRNP, PA, or nurse should adjust the doses based on the patient's withdrawal symptoms include sweats, chills, nausea, vomiting, goose bumps, runny nose, tearing eyes, yawning, etc. The CRNP, PA or nurse may use the COWS to document the patient withdrawal. If the patient complains of withdrawal symptoms 24 hours after the last dose contact the physician." Patient # 11 was admitted June 4, 2010. A standard order was used to order the initial dose and then the increases were left to the discretion of the nursing staff over the next week of the induction phase. The standard dosing order written in the physical stated, " #6. During the first 30 days of treatment after the Certified Registered Nurse Practitioner (CRNP), Physician Assistant (PA), or nurse shall adjust the dose of methadone upward by 5 mg for stabilization of withdrawal symptoms. The CRNP, PA or nurse must wait 5 days after adjusting the dose to adjust the dose upward again. They may not exceed the withdrawal symptoms after the first 30 days, contact the physician. #7 The CRNP, PA, or nurse should adjust the doses based on the patient's withdrawal symptoms include sweats, chills, nausea, vomiting, goose bumps, runny nose, tearing eyes, yawning, etc. The CRNP, PA or nurse may use the COWS to document the patient withdrawal. If the patient complains of withdrawal symptoms 24 hours after the last dose contact the physician." Patient # 12 was admitted July 30, 2010. A standard order was used to order the initial dose and then the increases were left to the discretion of the nursing staff over the next week of the induction phase. The order written in the physical stated, " #6. During the first 30 days of treatment after the Certified Registered Nurse Practitioner (CRNP), Physician Assistant (PA), or nurse shall adjust the dose of methadone upward by 5 mg for stabilization of withdrawal symptoms. The CRNP, PA or nurse must wait 5 days after adjusting the dose to adjust the dose upward again. They may not exceed the withdrawal symptoms after the first 30 days, contact the physician. #7 The CRNP, PA, or nurse should adjust the doses based on the patient's withdrawal symptoms include sweats, chills, nausea, vomiting, goose bumps, runny nose, tearing eyes, yawning, etc. The CRNP, PA or nurse may use the COWS to document the patient withdrawal. If the patient complains of withdrawal symptoms 24 hours after the last dose contact the physician." Patient # 13 was admitted December 11, 2009. A standard order was used to order the initial dose and then the increases were left to the discretion of the nursing staff over the next week of the induction phase. The standard dosing order written in the physical stated, " #6. During the first 30 days of treatment after the Certified Registered Nurse Practitioner (CRNP), Physician Assistant (PA), or nurse shall adjust the dose of methadone upward by 5 mg for stabilization of withdrawal symptoms. The CRNP, PA or nurse must wait 5 days after adjusting the dose to adjust the dose upward again. They may not exceed the withdrawal symptoms after the first 30 days, contact the physician. #7 The CRNP, PA, or nurse should adjust the doses based on the patient's withdrawal symptoms include sweats, chills, nausea, vomiting, goose bumps, runny nose, tearing eyes, yawning, etc. The CRNP, PA or nurse may use the COWS to document the patient withdrawal. If the patient complains of withdrawal symptoms 24 hours after the last dose contact the physician." Patient # 14 was admitted March 29, 2010. A standard order was used to order the initial dose and then the increases were left to the discretion of the nursing staff over the next week of the induction phase. The standard dosing order written in the physical stated, " #6. During the first 30 days of treatment after the Certified Registered Nurse Practitioner (CRNP), Physician Assistant (PA), or nurse shall adjust the dose of methadone upward by 5 mg for stabilization of withdrawal symptoms. The CRNP, PA or nurse must wait 5 days after adjusting the dose to adjust the dose upward again. They may not exceed the withdrawal symptoms after the first 30 days, contact the physician. #7 The CRNP, PA, or nurse should adjust the doses based on the patient's withdrawal symptoms include sweats, chills, nausea, vomiting, goose bumps, runny nose, tearing eyes, yawning, etc. The CRNP, PA or nurse may use the COWS to document the patient withdrawal. If the patient complains of withdrawal symptoms 24 hours after the last dose contact the physician." Patient # 15 was admitted December 7, 2009. A standard order was used to order the initial dose and then the increases were left to the discretion of the nursing staff over the next week of the induction phase. The order written in the physical stated, " #6. During the first 30 days of treatment after the Certified Registered Nurse Practitioner (CRNP), Physician Assistant (PA), or nurse shall adjust the dose of methadone upward by 5 mg for stabilization of withdrawal symptoms. The CRNP, PA or nurse must wait 5 days after adjusting the dose to adjust the dose upward again. They may not exceed the withdrawal symptoms after the first 30 days, contact the physician. #7 The CRNP, PA, or nurse should adjust the doses based on the patient's withdrawal symptoms include sweats, chills, nausea, vomiting, goose bumps, runny nose, tearing eyes, yawning, etc. The CRNP, PA or nurse may use the COWS to document the patient withdrawal. If the patient complains of withdrawal symptoms 24 hours after the last dose contact the physician." Patient # 17 was admitted May 5, 2010. A standard order was used to order the initial dose and then the increases were left to the discretion of the nursing staff over the next week of the induction phase. The order written in the physical stated, " #6. During the first 30 days of treatment after the Certified Registered Nurse Practitioner (CRNP), Physician Assistant (PA), or nurse shall adjust the dose of methadone upward by 5 mg for stabilization of withdrawal symptoms. The CRNP, PA or nurse must wait 5 days after adjusting the dose to adjust the dose upward again. They may not exceed the withdrawal symptoms after the first 30 days, contact the physician. #7 The CRNP, PA, or nurse should adjust the doses based on the patient's withdrawal symptoms include sweats, chills, nausea, vomiting, goose bumps, runny nose, tearing eyes, yawning, etc. The CRNP, PA or nurse may use the COWS to document the patient withdrawal. If the patient complains of withdrawal symptoms 24 hours after the last dose contact the physician."	Plan of Correction The Program Director provided a training to Medical Director and Physician regarding administration of medication. Medical Director or Physician will order all initial and subsequent dose schedules. The Standard order was removed at this time and the medical director or physician will sign off on all medication orders. Program Director to review via chart audits to ensure compliance and this is effective as of 12/13/2010
709.91(b)(6) LICENSURE Intake and admission 709.91. Intake and admission. (b) Intake procedures shall include documentation of: (6) Psychosocial evaluation.
Observations Based on the review of patient records and administrative documentation, the facility failed to ensure the psychosocial evaluations were a clinical assessment of the historical data collected or completed within the policy-stated seven days of admission. The findings include: Seventeen patient records were reviewed on November 16-17, 2010. Sixteen patient records were reviewed for psychosocial evaluations. Twelve out of sixteen patient records, specifically, # 1, 2, 4, 6, 7, 8, 10, 12, 13, 14, 15, and 17 and had psychosocial evaluations that did not include a clinical assessment. The documents that were completed contained a patient reported information without the clinician's impressions. Additionally, patient record # 5 failed to have a psychosocial evaluation completed within the required seven days. Patient # 5 was admitted on November 3, 2010 and to date there was no psychosocial evaluation documented in the patient record.	Plan of Correction Clinical assessments of the historical data collected will be complete and inclusive in all Psychosocial Evaluations. This will be immediate and on-going. An in-service training on the Psychosocial Evaluation, including, but not limited to, documentation of clinical assessments and time frames the psychosocial evaluation is to be completed will be completed on 12/22/2010. Clinical Supervisors will monitor for compliance via monthly chart audits and before signing off on all treatment plans.
709.92(a)(3) LICENSURE Treatment and rehabilitation services 709.92. Treatment and rehabilitation services. (a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of: (3) Proposed type of support service.
Observations Based on the review of patient records, the facility failed to document the proposed type of support services on each treatment plan in 5 of 15 patient records. The findings included: Seventeen patient records were reviewed during the annual licensing inspection . Fifteen patient records were required to document individualized treatment plans which included the proposed type of support services for the client while in treatment. The proposed support services were not documented on the treatment plans in client records # 2, 3, 7, 10, and 13.	Plan of Correction The Program Director and Clinical Supervisor will provide a training to Clinical staff on 12/29/10 regarding documentation of proposed support services in an individual treatment plan. Effective 12/29/10 prior to completion of the treatment plan both the clinical supervisor and the lead counselor will review each plan prior to approving the plan to ensure the support services are included. Clinical Supervisor will be responsible.