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 March 10-11, 2009 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 April 14, 2009.
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Plan of Correction
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715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on the review of patient records, the facility failed to ensure the patient signed the informed consent prior to the administration of a narcotic agent in two of four patient records.
The findings include:
Ten patient records were reviewed on March 10 and 11, 2009. Informed consent documentation was required in four patient records. The facility did not document informed patient consents prior to the administration of a narcotic agent in patient records # 1 and 3. Patient # 1 was admitted October 8, 2008 and signed the consent to administer an agent on November 5, 2008. Patient # 3 was admitted October 9, 2008 and signed the consent to administer an agent on November 20, 2008.
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Plan of Correction
The job description of the medical team and the doctor in particular has been redefined and reviewed. All informed consents and other signatured mandated forms will be signed prior to the patirnt receiving their first dose of Methadone.this is the sole responsibility of the doctor to obtain signatures before signing the order to dose. this will be furthered monitored by the Director and Clinical Supervisor.
The time line is Immediate and ongoing. |
715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
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Observations
Based on the review of patient records, the facility failed to ensure the physician documented the rationale for permitting take home medication privileges in two of four patient records.
The findings include:
Ten patient records were reviewed on March 10 and 11, 2009. Documentation of the physician's rationale for permitting take home medications was required in four patient records. The facility did not document the physician's rationale for permitting take home medication in patient records # 5 and 9.
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Plan of Correction
The doctor will start immediately to address changes in patient's treatment; especially in dose changer and granting take homes or increasinfg such. this will be done with a PDAP note in addition to signing reqiured criteria forms. The doctor will be solely responsible for his own notes, and will be monitored by the director and clinical supervisor.
Time lines are 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 the review of patient records, the facility failed to restrict the reasons for involuntary termination to those allowed by regulation in two of two patient records.
The findings include:
Ten patient records were reviewed on March 10 and 11, 2009. Two patient records were reviewed for involuntary termination documentation. Patient # 6 and patient # 8 contained documentation of being placed on an administrative detoxification for not being financially compliant. The facility failed to address the issue through therapeutic measures prior to initiating the involuntary detoxification.
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Plan of Correction
The entire staff has been told that under no circumstances should the reason for discharge be financial only. If the person has a pattern of financial irresponsibility then there needs to be assistence offered and other appropriate interventions. All needs to well documented. When a patient does have regular problems with payments, chances are that there are also other areas of non-compliance which should also have been addressed prior to other actions.
this will be reinforced on a regular basis with total staff.
Monitoring this approach will the responsibility of the dorector and the clinical supervisor.
The tike line is immediate and ongoing.
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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 the review of patient records, the facility failed to provide the required information regarding the patient's progress and status in the clinical notes in six of six patient records.
The findings include:
Ten patient records were reviewed on March 10 and 11, 2009. Six patient records were reviewed for progress notes. 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 # 1, 2, 3, 6, 9 and 10.
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Plan of Correction
an "In-service" session will be held with all staff to better understand the structure AND content of the PDAP notes.
Although changes and progress is documented in the "General Note" of each Treatment Plan, it will also be required that the "P" (plan) will contain clinical/therapuetic information and not just the next session date. The notes are the responsibility of the counselors; the monitoring and the in-services are the responsibility of the Clinical Supervisor.
The In-service will occur by May 8,2009 and monitoring is immediate and ongoing. |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on the review of patient records, the facility failed to document psychosocial evaluations in six of six patient records.
The findings include:
Ten patient records were reviewed on March 10 and 11, 2009. Psychosocial evaluations were required in six patient records. The narcotic treatment program did not document psychosocial evaluations in patient records # 1, 2, 3, 4, 5 and 10.
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Plan of Correction
The Clinical Supervisor will start immediately to audit for the inclusion of the Psychosocial Form present in the charts (currently the Hard copy of each chart), and was completed timely as policy addresses. The presence of Psychosocial will be documented in the electronic chart and where to find it. Assessment update will occur in the activities (general)notes. This is also the responsibility of the Clinical Supervisor to monitor.
Time line is immediate and ongoing. |
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 narcotic treatment program failed to document treatment plan updates in three of three patient records.
The findings include:
Ten patient records were reviewed on March 10 and 11, 2009. Treatment plan updates were required in three 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 # 1, 3 and 10.
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Plan of Correction
The counselors will receive training again to ensure that a patients progress is documented in the Treatment Plan updates in the "General Box" under the dimensions, SNAP and the "Changes" area. This will also be referred to from the general note in the activity note section.
The training will occur by May 8,2009.This training will be done by the Clinical Supervisor who will also do the ongoing monitoring.
The monitoring will be immediate and ongoing. |