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 January 18-20, 2011 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 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 February 22, 2011.
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Plan of Correction
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715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
Based on a review patient records, interviews with the facility director and clinical supervisor, the facility failed to fully inform each female patient of the possible risk to her and her unborn child from continued use of illicit drugs and from the use of, or withdrawal from, a narcotic drug administered or dispensed by the program for comprehensive maintenance or detoxification treatment in five of six client records.
The findings include"
Twenty one patient records were reviewed on January 18-20, 2011. Six patient records reviewed were of female patients who must be informed of the possible risk to her and her unborn child. Per regulation, the narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from, a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment. The facility did not inform the patient of the risks in patient records # 2, 4, 10, 12 and 13.
Patient # 2, was admitted on November 17, 2010. There was no documentation that the narcotic treatment program ensured that the female patient was fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment. The patient was informed only that methadone is transmitted to the unborn child and will cause physical dependence.
Patient # 4, was admitted on October 8, 2010. There was no documentation that the narcotic treatment program ensured that the female patient was fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment. The patient was informed only that methadone is transmitted to the unborn child and will cause physical dependence.
Patient # 10, was admitted on September 7, 2010. There was no documentation that the narcotic treatment program ensured that the female patient was fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment. The patient was informed only that methadone is transmitted to the unborn child and will cause physical dependence.
Patient # 12, was admitted on November 24, 2010. There was no documentation that the narcotic treatment program ensured that the female patient was fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment. The patient was informed only that methadone is transmitted to the unborn child and will cause physical dependence.
Patient # 13 , was admitted on October 27, 2010. There was no documentation that the narcotic treatment program ensured that the female patient was fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment. The patient was informed only that methadone is transmitted to the unborn child and will cause physical dependence.
The facility director and clinical supervisor were interviewed on January 20, 2011. They confirmed that the patients were not informed of all the required risks. The facility director stated they are moving towards computerized records and in the transfer from paper records to computerized records, the required information was missed in the computerized form.
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Plan of Correction
The Medical Director shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawl from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment. Each female patient shall be informed prior to admission and consent to narcotic treatment. The patient's consent to narcotic treatment and their acknowledgment of the potential benefits and possible risks involved will be documented in the patient's record. The Medical Director will review the information with female patients who become pregnant while in the program. The review will be documented in the patient's record. Timeframe for compliance is immediate and ongoing. The Facility Director will be responsible for oversight. |
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 interviews, the facility failed to consider the criteria for take-home privileges in two of seven patient records.
The findings include:
Twenty-one patient records were reviewed on January 18-20, 2011. Seven patient records were reviewed for compliance with the regulations regarding take-home medications. Per regulation, the narcotic treatment physician shall consider the following in exercising reasonable clinical judgment, a patient is responsible in handling narcotic drugs: absence of recent abuse of drugs (narcotic or non-narcotic), including alcohol, regular narcotic treatment program attendance, absence of serious behavioral problems at the narcotic treatment program, absence of known recent criminal activity, stability of the patient 's home environment and social relationships, length of time in comprehensive maintenance treatment. assurance that take-home medication can be safely stored within the patient's home, and whether the rehabilitative benefit to the patient derived from decreasing the frequency of attendance outweighs the potential risks of drug diversion. The facility failed to consider the patient's current criteria for take-home privileges in patient records # 3 and 4.
Patient # 3 was admitted into treatment on December 14, 2010. Patient # 3 transferred into treatment from another narcotic treatment program and was immediately granted take-home privileges. There was no documentation that the patient's current criteria had been considered for granting take-home privileges in patient record # 3.
Patient # 4 was admitted into treatment on October 8, 2010. Patient # 4 transferred into treatment from another narcotic treatment program and was immediately granted take home privileges. There was no documentation that the patient's current criteria had been considered for granting take home privileges in patient record # 4.
The facility director and clinical supervisor were interviewed on January 20, 2011. They reviewed patient records # 3 and 4 and confirmed that there was no documentation that the patient's current criteria had been considered prior to granting take-home privileges. They reported the criteria was not reviewed due to the patients transferring into treatment from another narcotic treatment program where they were receiving take home privileges.
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Plan of Correction
The Program Director will hold an inservice training to review and reinforce the requirment to consider and document the eight point criteria for take home privileges. The training will stress completing a new criteria consideration and required documentation for Discovery House intratransfers. The training will include the Medical Director and Clinical Staff and be completed within 14 days. The Facility 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 observation of dosing, the facility failed to administer and dispense the medication in a manner that was consistent with the facility's policy.
The findings include:
Methadone monitoring was conducted January 18-20, 2011. Dosing was observed on January 19, 2011. Per policy, there are to be no hats, sunglasses, beverages or children at the doing window. It was observed that a patient at the window was wearing a hat and that the dispensing nurse did not have the patient remove his hat prior to being dosed.
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Plan of Correction
The Medical Director and Facility Director conducted an inservice training on January 28th 2011 with the Dispensing Staff to address the citation. The training covered regulations and policies concerning patient identification at the dispensing area. The Medical Director will conduct random observations of the dispensing process to ensure compliance with the regulation and policies. The Facility Director will be responsible for oversight. |
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 three of seven patient records.
The findings include:
Twenty one patient records were reviewed January 18-20, 2011. Seven patient records were reviewed for an average of 2.5 hours of psychotherapy hours during the patient's first 2 years of treatment. The facility did not document an average of 2.5 hours of psychotherapy hours during the patient's first 2 years of treatment in patient records # 2, 4 and 10.
Patient # 2 was admitted on November 17, 2010. From November 17, 2010 to January 17, 2011, the patient received and average of .41 psychotherapy hours. The patient had no documented psychotherapy hours for the month of November 2010, 1.25 psychotherapy hours were documented for December, 2010 and there were no documented psychotherapy hours for the month of January, 2011 as of January 17, 2011.
Patient # 4 was admitted on October 8, 2010. The patient was a transfer from another narcotic treatment program. The patient was admitted to the transferring program on July 29, 2010. From October 8, 2010 to January 8, 2011, the patient received an average of 1.75 psychotherapy hours. The patient had no documented psychotherapy hours for the month of October, 2010, 2.50 hours for the month of November, 2010, 2.75 psychotherapy hours for the month of December, 2010 and no documented psychotherapy hours for month of January, 2011 as of January 17, 2011.
Patient # 10 was admitted on September 7, 2010. The patient received an average of 2.08 psychotherapy hours for the months of October, November and December 2010. The patient received 2.25 psychotherapy hours in October, 2010, 2.50 psychotherapy hours in November, 2010 and 1.5 psychotherapy hours in December 2010.
The facility director and clinical supervisor were interviewed on January 20, 2011. They stated that the orientation group and HIV educational groups were being looked at as part of the psychotherapy hours. The clinical supervisor stated this will be remedied.
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Plan of Correction
The Clinical Supervisor will implement weekly reviews of required and provided direct service hours. Compliance will be adressed during weekly clinical team meetings and individual clinical supervision. Action plans will be required when counselors do not provide ample psyhotherapy services. Timeframe to implement is immediate and ongoing. The Program Director and Clinical Supervisor will be responsible for oversight. |
715..23(b)(1) LICENSURE Patient records
(b) Each patient file shall include the following information:
(1) A complete personal history.
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Observations
Based on a review of patient records and interviews with the facility director and the clinical supervisor, the facility failed to document complete personal histories in four of ten patient records.
The findings include:
Twenty one patient records were reviewed between January 18, 2011 and January 20, 2011. Ten patient records were required to have a complete personal history. Four of the ten patient records failed to include complete personal histories. The facility did not document a complete personal history in patient records # 1, 2, 3 and 4.
Patient # 1 was admitted to treatment on August 6, 2010. The personal history, completed on August 6, 2010, addressed only the current educational and employment/vocational status and did not provide the patient's history for these two areas.
Patient # 2 was admitted to treatment on November 17, 2010. The personal history, completed on November 16, 2010, addressed only the current educational and employment/vocational status and did not provide the patient's history for these two areas.
Patient # 3 was admitted to treatment on December 14, 2010. The personal history, completed on December 7, 2010, addressed only the current educational and employment/vocational status and did not provide the patient's history for these two areas.
Patient # 4 was admitted to treatment on October 8, 2010. The personal history, completed on October 7, 2010, addressed only the current educational and employment/vocational status and did not provide the patient's history for these two areas.
During an interview with the facility director and the clinical supervisor on January 20, 2011, they confirmed that the data collected for educational and employment histories was current status and did not always include the historical perspective.
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Plan of Correction
An in-service training will be provided by the Clinical Supervisor for all clinical staff involved in the intake and admissions process. The training will address the documentation of personal histories and techniques on how to obtain the information. The Clinical Supervisor will be responsible to review psychosocial evaluations during clinical quality reviews to ensure compliance. Program Director will be responsible for oversight. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on the review of patient records and interviews with the facility director and the clinical supervisor, the facility failed to document the attempt or completion of follow up information regarding the patient per agency policy in five of seven patient records reviewed.
The findings include:
Twenty one patient records were reviewed on January 18-20, 2011. Seven patient records were reviewed for follow-up documentation. Per policy, follow up is to be attempted at 14 and 30 days of discharge. The facility did not document follow up per policy in patient records # 15, 16, 17, 19 and 20.
Patient # 15 was admitted on February 26, 2010 and discharged on September 23, 2010. Follow up contact was to be completed on October 7 and October 23, 2010. There was no documentation that follow up had been completed or attempted.
Patient # 16 was admitted on October 9, 2010 and discharged on November 4, 2010. Follow up contact was to be completed on November 18 and December 4, 2010. There was no documentation that follow up had been completed or attempted.
Patient # 17 was admitted on September 3, 2009 and discharged on August 24, 2010. Follow up contact was to be completed September 7 and September 24, 2010. Follow ups documented in the patient record were dated September 22, 2010 and October 7, 2010. There was no 14 day follow up documented.
Patient # 19 was admitted on April 14, 2010 and discharged on October 12, 2010. Follow up contact was to be completed October 26 and November 12, 2010. Follow ups documented in the patient record were dated October 27, 2010 and October 29, 2010. There was no 30 day follow up documented.
Patient # 20 was admitted on May 12, 2010 and discharged on November 3, 2010. Follow up contact was to be completed November 17 and December 3, 2010. Follow up documented in the patient record was dated November 15, 2010. There was no 30 day follow up documented.
The facility director and clinical supervisor were interviewed on January 20, 2010. The supervisor stated that there were no signed releases permitting follow up in patient records #15 and 16. It was discussed that follow up is required unless there is documentation of the patient refusal to participate in follow up. The supervisor stated that documentation will be placed in the patient records of the acceptance or refusal of follow up. No further documentation was provided for the remaining records.
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Plan of Correction
The Clinical Supervisor will hold an inservice training concerning the regulation and facility policy requiring follow up contacts to be completed at 14 and 30 day intervals after discharge. The training will address the requirements and documentation. The Clinical Supervisor will address the documentation requirement in weekly supervision to ensure compliance. The training will be completed within the next 14 days. The Facility Director will do sporadic chart audits for oversight. |