INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and a methadone monitoring inspection conducted on February 10-12, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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 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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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
A review of fire drill logs from November 2018 through January 2020 was conducted during the onsite inspection on February 10-12, 2020. The facility failed to document on the fire drill records for November and December 2019 whether the fire alarm or smoke detector was operative.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Although the smoke detectors were set off during the monthly fire drill It was failed to be documented in the fire drill form. Starting immediately all fire drills will be documented that the fire alarm or smoke detector were operative during the monthly fire drill. This will be monitored by the director. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of the policy and procedures manual on February 10-12, 2020, the facility failed to show documentation of the project director annually updating and signing the manual. The last documentation was dated January 18, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The comprehensive Treatment Center Group President Kim Sanderson signed the Policy and Procedures Manuel on February 5, 2020 it is now in the policy and procedure Manuel |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records on February 10-12, 2020, the facility failed to ensure that there was appropriate documentation of written acknowledgement by the client that the client had been made aware of all of their rights in client record # ' s 1, 5, 6, and 7. The client rights, both the electronic signed version and the handbook were missing that the facility shall document reasons for removing portions of the client ' s record.
Client #1 was admitted on April 1, 2019 and was still active at the time of the inspection.
Client #5 was admitted on February 20, 2019 and was still active at the time of the inspection.
Client #6 was admitted on June 25, 2019 and discharged on September 29, 2019.
Client #7 was admitted on April 12, 2019 and was still active at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Services Department will revise the Client Rights policy and procedure and the Patient Handbook to bring the Policy and Patient Handbook into conformance with the regulations. Patients 1, 5 and 7 will sign the revised form by 3/31/20. Project management will review policy and procedure revisions with all staff at the March staff meeting. |
715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of the physician timesheets for the months of November and December 2019 on February 10-12, 2020, the facility failed to provide at least one hour of physician time a week, on site for every ten patients.
During the week of November 17-23, 2019, the patient census was 557. The facility was required to provide at least 55.7 physician hours. There were 54 physician hours documented.
During the week of December 8-14, 2019, the patient census was 559. The facility was required to provide at least 55.9 physician hours. There were 54.5 physician hours documented.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Physician hours will be monitored and submitted per State regulation of at least one hour of physician time a week for every 10 patients. This will be monitored by the program director. |
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 a review of client records on February 10-12, 2020, the facility failed to include all required information on the methadone patient consent form in client records #5 and 6. The patient consent form did not include that methadone is transmitted to the unborn child and will cause physical dependence.
Client #5 was admitted on February 20, 2019 and was still active at the time of the inspection.
Client #6 was admitted on June 25, 2019 and discharged on September 29, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Risk During Pregnancy
- Knowledge of the effects of methadone on pregnant women and their unborn child is presently inadequate to guarantee that methadone may not produce significant or serious side effects.
- Methadone is transmitted to the unborn child and may cause physical dependence. The newborn may show irritability and other ill effects from the use of methadone for a brief time following birth. This may require medical intervention.
- Abrupt withdrawal from methadone may adversely affect the unborn child, which could result in fetal death and/or premature labor.
- The use of other drugs in addition to methadone may harm the patient and/or unborn child.
- Currently, research shows that mothers maintained on methadone can safely breastfeed, UNLESS they are HIV positive, or are known to have another disease or infection where breastfeeding is contraindicated. Hepatitis C is not considered a contradiction for breast-feeding.
- Methadone is transmitted to the unborn child and may cause physical dependence. The newborn may show irritability and other ill effects from the use of methadone for a brief time following birth. This may require medical intervention.
This has been added to the informed consent to address the citation.This will be adding into the EMR by 3/31/20 at that time we will have patietn #5 sign the new form. The clinic director will monitor to check implementation into the EMR.
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715.16(d)(1-3) LICENSURE Take-home privileges
(d) A narcotic treatment program may make exceptions to the requirements in subsection (c) relating to the length of time of satisfactory adherence to narcotic treatment program rules and number of days of take-home medication when, in the reasonable clinical judgment of the narcotic treatment physician, which is documented in the patient record:
(1) A patient has a permanent physical disability.
(2) A patient has a temporary disability.
(3) A patient has an exceptional circumstance such as illness, personal or family crisis, or travel which interferes with the patient 's ability to conform to the applicable mandatory attendance schedules. In all cases, the patient shall demonstrate an ability to responsibly handle narcotic drugs.
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Observations
Based on a review of client records on February 10-12, 2020, the facility failed to document that applicable criteria have been met prior to granting 13-day take home privileges for client # ' s 3 and 8.
Client #3 was admitted on January 14, 2016 and was still active at the time of the inspection.
Client #8 was admitted on June 5, 2012 and discharged on December 5, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The 13 day take-home status was stopped after the audit close out. All 13 day take home have been reduced to 6 day. Going forward 13 day will only be given by exception according to the state guidelines. This will be monitored by the Clinical Supervisor and Program Director. |
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 client records on February 10-12, 2020, the facility failed to provide patient #7 with an average of 2.5 hours of psychotherapy per month during the patient ' s first two years of treatment.
Client #7 was admitted on April 12, 2019 and was still active at the time of the inspection. For the time period of November 2019 through January 2020, the client received a total of 6.5 hours of psychotherapy, which averages to 2.1 hours per month.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Patients will do the required 2.5 hours of counseling per month. Counselors will make every effort to have the counseling completed each month. If the patient does not show a no-show note will be placed in the chart to show attempts to get the required hours. This will be addressed in the next Staff Meeting in March. This will be monitored by the clinical supervisor/lead counselor and Program Director. |