INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection pertaining to the plans of correction for the January 20, 2011 methadone monitoring inspection. The follow-up inspection was conducted on August 24, 2011 by staff from the the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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. The following deficiencies were identified during this inspection.
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Plan of Correction
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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 follow-up was conducted on August 24, 2011. Dosing was observed on August 24, 2011. Per policy, there are to be no hats, sunglasses, beverages or children at the doing window. It was observed that a patient had their child with them at the dosing window.
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Plan of Correction
Plan of Correction:
The Medical Director and Facility
Plan of Correction:
Director will conduct an inservice training on September 26, 2011 with the Dispensing Staff to address the citation. The training will focus on the regulation and the Discovery House policy that only authorized staff and patients who are receiving medication shall be permitted in the dosing area. The Medical Director will conduct random observations of the dispensing process to ensure compliance with regulation and policies. The Facility Director will be responsible for the oversight.
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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 three of three patient records.
The findings include:
Twenty one patient records were reviewed on August 24, 2011. Three patient records were required to have a complete personal history. Three of the three patient records failed to include complete personal histories. The facility did not document a complete personal history in patient records # 1, 2 and 7.
Patient # 1 was admitted to treatment on August 12, 2011. The personal history, completed on August 12, 2011, 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 July 15, 2011. The personal history, completed on July 15, 2011, addressed only the current employment/vocational status and did not provide the patient's history for this area.
Patient # 7 was admitted to treatment on April 22, 2011 The personal history, completed on April 22, 2011 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 August 24, 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
Plan of Correction:
An in-service training will be provided by the Clinical Supervisor for all clinical staff invovled in the intake and admissions process. The training will address the dcoumentation of personal histories and techniques on how to obtain informaton. The training will emphasize the requirement to document the patient's vocational and employment histories and how to identify any barriers related to their addition and/or psycho-social stressors.The clinical supervisor will be responsible to review psychosocial evalautions during clinical quality reviews to ensure compliance. Program
Director will be responsible for oversight.
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