INITIAL COMMENTS
|
This report is a result of an on-site inspection conducted for the approval to use a narcotic agent, methadone, in the treatment of narcotic addiction. This inspection was conducted on August 28-30, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House 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.
|
Plan of Correction
|
715.10(d) LICENSURE Pregnant patients
(d) Within 3 months after termination of pregnancy, the narcotic treatment physician shall enter an evaluation of the patient 's treatment status into her record and state whether she should remain in comprehensive maintenance treatment or receive detoxification treatment.
|
Observations
Based on the review of patient records, the narcotic treatment program failed to document, within three months after the termination of pregnancy, whether or not the patient should continue maintenance or receive detoxification treatment in one of one patient record.
The findings include:
Twenty four patient records were reviewed August 28-30, 2012. An evaluation of the patient's treatment status within three months after termination of pregnancy was required in one patient record. The narcotic treatment physician did not document this evaluation in patient record #1.
Patient # 1 was admitted into treatment on February 13, 2012 due to her pregnancy. The patient delivered on May 26, 2012. There was no documentation that the narcotic treatment physician evaluated the patient's treatment status to determine whether she should remain in comprehensive maintenance treatment or receive detoxification treatment as of August 30, 2012.
The Facility Director was interviewed on August 30, 2012 and confirmed the findings.
|
Plan of Correction
715.10(d) Pregnant patients: The citation was reviewed with the physician and physician's assistant on 9/21/2012. We are uncertain why an evaluation was not conducted within three months of termination of pregnancy. All patients, pregnant or not, are being evaluated prior to admission.
Should the program admit a pregnant woman without the initial evaluation, the following procedures will be followed to assure compliance:
1. The PA, who tracks all pregnant patients, will alert the physician if there is need for an assessment of a pregnant patient's treatment status following the termination of the pregnancy.
2. Physician will provide assessment of addiction and treatment status for patients terminating pregnancy, within three months of that termination.
3. PA will report at least quarterly to the director concerning all pregnant patients and need for assessment of any of those patients.
The physician and physician's assistant are responsible for implementing this procedure. The director is responsible for monitoring and compliance.
|
715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
|
Observations
Based on the review of patient records, the facility failed to maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and 709.28 (relating to confidentiality) in four of fifteen patient records.
The findings include:
Twenty four patient records were reviewed on August 28-30, 2012. Fifteen patient records were reviewed for confidentiality. The facility did not maintain the patient's confidentiality is patient records #1, 2, 11 and 17.
Patient #1 was admitted on February 13, 2012. The documentation in the patient record revealed that the patient's treatment was being funded by a third party payer. There was no release of information documented for the funding source.
Patient # 2 was admitted on December 2, 2011. A consent for the release of information for the parole officer was signed by the patient on December 5, 2011. The consent to release exceeded 709.28 (c)(2). The consent allowed for the release of the patient's medication history, current dose level, drug test results and the discharge summary. A consent for the release of information for the transportation entity was signed by the patient and included the release of the patient's dosing history and dose level.
Patient #11 was admitted on March 31, 2011. A consent for the release of information for the transportation entity was signed by the patient in March, 2012. The consent to release exceeded 709.28 (c)(2). The consent allowed for the release of the patient's current dose level.
Patient # 17 transferred from another narcotic treatment facility and was admitted on January 31, 2012. The admitting facility failed to obtain a release of information from the patient prior to confirming the patient's dose with the transferring facility.
The Facility Director was interviewed on August 30, 2012 and confirmed the findings.
|
Plan of Correction
715.11 Confidentiality of patient records: This regulation was violated in a number of ways. The director reviewed citations with counselors, administrative assistant and nurses on 9-17-12. Direction to staff is to 1. Assure releases do not exceed 709.28(c)(2), 2. Assure signing of release form prior to actual release, 3. Release only minimum necessary information as specified on the release form and 4. Assure release is signed prior to confirming patient dose with another facility.
The Clinical Supervisor will audit a sample of record releases during October and November 2012 to assure compliance.
Clinical Supervisor is responsible for completion of this corrective action plan and ongoing compliance.
|
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
|
Observations
Based on the review of patient records, the facility failed to document the results of documentation provided by the laboratories conducting the testing in patient in nine of eleven patient records.
The findings include:
Twenty four patient records were reviewed on August 28-30, 2012. Nine patient records were reviewed for the completion of urinalysis testing. The review of patient records for documentation of drug screen urinalysis results failed to include the documentation provided by the laboratories conducting the testing in patient records # 1, 2, 5, 6, 7, 8, 9, 10 and 11.
In staff interviews, it was reported that the urinalysis reports are discarded and not maintained on site. According to staff interviews and observation during the monitoring, results of the urinalysis tests are entered into the computer in a table format. In the review of this documentation, discrepancies were identified and staff were unable to provide the original documentation to address the issues raised during the monitoring.
The Facility Director and Nurse Manager were interviewed on August 30, 2012 and confirmed the findings.
|
Plan of Correction
715.14(a) Urine testing: The program has not been maintaining hard copies of the urinalysis reports. Nursing, administrative assistant and counseling staff were alerted to this citation on 9-17-2012. Director revised procedure so that all paper copies of UA results are maintained on site for future reference.
The nurse manager has been responsible for correcting this process and will maintain compliance in the future. Director will monitor compliance.
|
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
|
Observations
Based on the review of patient records, the facility failed to document that the narcotic treatment physician reviewed the dosage levels at least twice a year, in one of eight patient records.
The findings include:
Twenty five patient records were reviewed on August 28-30, 2012. Eight patient records were reviewed for the required semi-annual dose review by the narcotic treatment physician. The narcotic treatment physician did not document the semi annual dose review for patient # 10. The semi annual dose review for patient #10, dated August 29, 2012, was completed by the physician's assistant.
The Facility Director and Nurse Manager were interviewed in August 30, 2012 and confirmed the findings.
|
Plan of Correction
715.15(a) Medication dosage: Citation was reviewed with the physician and physician's assistant on 9-20-2012. The physician will complete all semi-annual dose reviews to determine a patient's therapeutic dosage.
The physician is responsible for completion of this corrective action plan. |
715.16(c)(3)(i-viii) LICENSURE Take-home privileges
(c) A narcotic treatment program shall require a patient to come to the narcotic treatment program for observation daily or at least 6 days a week for comprehensive maintenance treatment, unless a patient is permitted to receive take-home medication as follows:
(3) A narcotic treatment program may permit a patient to reduce attendance at the narcotic treatment program for observation to one time weekly and receive no more than a 6-day take-home supply of medication when in the reasonable clinical judgment of the narcotic treatment physician, which is documented in the patient record:
(i) A patient demonstrates satisfactory adherence to narcotic treatment program rules for at least 3 years.
(ii) A patient demonstrates substantial progress in rehabilitation.
(iii) A patient demonstrates responsibility in handling narcotic drugs.
(iv) A patient demonstrates that rehabilitation progress would improve by decreasing the frequency of attendance for observation.
(v) A patient demonstrates no major behavioral problems.
(vi) A patient is employed, is actively seeking employment, attends school, is a homemaker or is considered unemployable for mental or physical reasons.
(vii) A patient is not known to have abused alcohol or other drugs within the previous year.
(viii) A patient is not known to have engaged in any criminal activity within the previous year.
|
Observations
Based on a review of patient records, the facility failed to consider the criteria for granting a 6-day take-home supply of medication in one of one patient record.
The findings include:
Twenty four patient records were reviewed on August 28-30, 2012. One patient record was reviewed for a 6-day take-home supply of medication. The facility failed to document that the patient met the criteria for granting a six day take-home supply of medication in patient record # 9.
Patient # 9 was admitted into treatment on February 12, 2011. The patient had transferred into treatment from another narcotic treatment program. The patient was immediately granted privileges for a six day take-home supply of medication. The facility failed to document the rationale for the patient to have six day take home status.
The Facility Director was interviewed on August 30, 2012 and confirmed the findings.
|
Plan of Correction
715.16(c)(3) i-viii Take home privileges: Patients will not be granted take home privileges until the physician determines that the patient meets the criteria for take homes spelled out in 715.16 (a) ? (c). Instructions were provided to the physician on September 17, 2012 to diligently utilize the criteria in these regulations when considering all take homes at the MDT. This includes transfer patients who had take homes at their previous clinic as well as any 6 day take homes. The physician will approve all take homes based on the criteria in the regulations. The physician is responsible for correcting this citation.
In order to provide clarity and educate staff, the entire take home approval process will be studied against state regulations and DH policies and procedures. Revisions will be instituted by October 31, 2012, based on physician and director approval.
|
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
|
Observations
Based on the review of patient records, the facility failed to transfer the required patient files in three of four patient records.
The findings include:
Twenty four patient records were reviewed on August 28-30, 2012. Four patient records required the facility transfer specific patient files to the receiving narcotic treatment program as part of the transfer process. The facility did not document that the patient files were transferred in patient records # 14, 15 and 16.
Patient # 14 was admitted on August 11, 2011 and discharged as a transfer to another narcotic treatment facility on January 19, 2012. There was no documentation that the required patient information was provided to the receiving facility.
Patient # 15 was admitted on October 13, 2010 and was discharged as a transfer to another narcotic treatment facility on December 1, 2011. There was no documentation that the required patient information was provided to the receiving facility.
Patient # 16 was admitted on August 10, 2011 and discharged as a transfer to another narcotic treatment facility on June 21, 2012. There was no documentation that the required patient information was provided to the receiving facility.
The Facility Director was interviewed on August 30, 2012 and confirmed the findings.
|
Plan of Correction
715.20(1) Patient transfers: Staff transferred patients to other narcotic treatment facilities without documenting information released. Notice to counselors of this citation was provided on 9-17-2012. Based on regulation and policy, training of clinical staff will be provided on procedures for transfer of patients to other narcotic treatment facilities. This will include training on documentation of information released. Training will be completed by October 15, 2012. The clinical supervisor is responsible for completion of this corrective action plan and ongoing compliance with the standard. |
715..23(b)(1) LICENSURE Patient records
(b) Each patient file shall include the following information:
(1) A complete personal history.
|
Observations
Based on the review of patient records, the facility failed to document a complete personal history in two of four patient records.
The findings include:
Twenty four patient records were reviewed on August 28-30, 2012. Four patient reviewed required documentation of all required information in the personal history. The facility did not document a complete personal history in patient records # 3 and 4.
Patient # 3 admitted on July 24, 2012. The personal history, completed on July 31, 2012 consisted of current information and did not document a history of the patient's family, legal, employment/vocational and educational information.
Patient # 4 admitted on June 1, 2012. The personal history, completed on June 18, 2012 consisted of current information and did not document a history of the patient's family, legal, employment/vocational and educational information.
The Clinical Supervisor was interviewed on August 30, 2012 and confirmed the findings.
|
Plan of Correction
715.23(b)(1) Patient records: Counselors were informed on 9-17-2012 of this citation concerning inadequate documentation of personal history, including family, legal, employment/vocational and educational information. The clinical supervisor will provide training on complete documentation to the clinical staff by October 15, 2012. During November 2012 the clinical supervisor will audit at least one record of each counselor to assure that personal histories are completed. The clinical supervisor is responsible for compliance with this regulation. |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
|
Observations
Based on the review of patient records, the facility failed to document a psychosocial evaluation of the patient in three of five patient records.
The findings include:
Twenty four patient records were reviewed on August 28-30, 2012. Five patient records reviewed required documentation of psychosocial evaluations of the patient. The facility did not document a psychosocial evaluation of patients records # 3, 4 and 6.
Patient # 3 was admitted on July 24, 2012. The psychosocial evaluation, completed on July 31, 2012 contained a repeat of the historical data, patient reported information and did not include a clinical assessment of the information.
Patient # 4 was admitted on June 1, 2012. The psychosocial evaluation, completed on June 18, 2012 contained a repeat of the historical data and patient reported information and did not include a clinical assessment of the information.
Patient # 6 was admitted on March 22, 2012. The psychosocial evaluation, completed on April 2, 2012 contained a repeat of the historical data, patient reported information and did not include a clinical assessment of the information.
The Clinical Supervisor was interviewed on August 30, 2012 and confirmed the findings.
|
Plan of Correction
715.23(b)(15) Patient records: Counselors were informed on 9-17-2012 of this citation concerning failures to complete a clinical assessment of the patient as part of the psychosocial evaluation. The clinical supervisor will provide training on clinical assessment documentation to the clinical staff by October 15, 2012. During November 2012 the clinical supervisor will audit at least one record of each counselor to assure that personal histories are completed. The clinical supervisor is responsible for compliance with this regulation. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
|
Observations
Based on the review of administrative documentation, the facility failed to provide documentation to the Department of unusual incident reports involving incidents with the potential for negative community reaction or which the facility director believes may lead to community concern.
The findings include:
The unusual incident reports were reviewed on August 29, 2012 . There was documentation of an unusual incident report dated May 16, 2012 that indicated a patient had a weapon on the premises. An incident report dated May 3, 2012 documented that a patient arriving at the clinic was approached by staff in the parking lot after she had almost dropped the baby carrier in which her child was sitting. The woman was found to be under the influence. Child endangerment was also noted in the report. Neither incident had been submitted to the Department as required.
The Facility Director was interviewed on August 30, 2012 and confirmed the findings.
|
Plan of Correction
715.28(c)(1-5) Unusual incidents: The program failed to report unusual incidents to the state. The Director informed all staff on 9-17-2012 of this citation and the need to report unusual incidents. Beginning immediately the director, with back up by the clinical supervisor in the director's absence, will file Unusual Incident Reports within 48 hours of the incident. Reportable incidents include 1. Complaint of patient abuse. 2. Death or serious injury. 3. Significant disruption of services. 4. Incidents with potential for negative community reaction and 5. Drug related hospitalization of patient. The director is responsible for implementation of this standard. |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
|
Observations
Based on a review of patient records, the facility failed to ensure that verbal medication orders are signed with 24 hours thereafter by the prescribing physician, as required by regulation and facility policy and procedure, in one of two patient records.
The findings include:
Twenty four patient records were reviewed on August 28-30, 2012. Two patient records were reviewed for documentation of a verbal medication order. A verbal medication order was not signed by the prescribing physician within 24 hours in patient # 11.
Patient #11 was admitted on March 31, 2011. A verbal medication order, received by nursing on March 29, 2012, was signed by the prescribing physician on April 1, 2012.
The Facility Director and Nurse Manager were interviewed on August 30, 2012 and confirmed the findings.
|
Plan of Correction
709.32(b) Medication control: The citation concerning a late signing of a verbal medication order was reviewed with the physician on 9-14-2012. The physician will sign orders at least every 24 hours. The nurse will notify the physician when there is immediate need for a verbal order to be signed. If the electronic medical records system is down, a paper system of signed verbal orders will be implemented to assure signatures within 24 hours. The nurse manager will audit a sample of orders during October 2012 to assure compliance. The physician is responsible for implementing this corrective action plan. |