INITIAL COMMENTS
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This report is a result of an administrative review of the written report of the findings 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 October 7, 2013, to October 11, 2013, by staff from the Program Licensure Division. Based on the findings of the on-site inspection, Habit OPCO, 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 administrative review:
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Plan of Correction
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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 a review of patient records, the narcotic treatment program failed to ensure the physician documented the rationale for granting take-home privileges in two of three records reviewed.
The findings included:
Eleven patient records were reviewed October 9, 2013 through October 11, 2013. Three patient records were reviewed for take-home privilege documentation. The narcotic treatment program failed to document the narcotic treatment physician's rationale for determining take-home privilege in records, #10 and 11.
Patient #10 was admitted on April 3, 2012. An order to provide take-home privileges was dated September 26, 2013. The patient record did not include the physician's rationale for granting the take-home privilege at the time of the review.
Patient #11 was admitted on June 21, 2012. An order to provide take-home privileges was dated January 3, 2013. The patient record did not include the physician's rationale for granting the take-home privilege at the time of the review.
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Plan of Correction
A meeting was held to discuss this practice with the NTP on site in Dunmore and the Nurse Manager. The NTP was educated as to the expectations under §715.16(a)(3) and further trainings will follow. Edits have since been made to the take home application which provides for specific space for NTP to make this entry on all future take home applications. HOI-Dunmore expects to be in full compliance to this requirement by December 2013. The nurse manager will review the physicians documentation and the Clinical Director will ensure that these are completed properly through the use of random quarterly chart audits. |
715.20 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.
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Observations
Based on a review of administrative documentation and a review of patient records, the narcotic treatment program failed to ensure a transfer within 7 days of patient request in one of two records.
The findings included:
Eleven patient records were reviewed October 9, 2013 through October 11, 2013. Two patient records required the program transfer specific patient record documentation to the receiving narcotic treatment program as part of the transfer process. The narcotic treatment program failed to ensure a transfer request within 7 days in record # 6
The narcotic treatment program policies and procedures were reviewed on October 10, 2013. No documentation was made available during the methadone monitoring indicating the narcotic treatment program had developed policies and procedures regarding the transfer initiation within 7 days of patient request.
Patient # 6 was admitted on July 30, 2013, and discharged as a transfer to another narcotic treatment program on October 7, 2013. A consent to release information listing the information to be transferred to the receiving narcotic treatment program was not documented in the record. There was no documentation to verify the transfer within 7 days of the request at the time of the review.
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Plan of Correction
The patient referenced was an internal transfer to another Habit OPCO program within the project. Because the patient was transferred within the project, to staff members who worked within the project, the staff members handling the transfer determined that no consent form was required to be completed. To ensure compliance with this deficiency, Habit OPCO staff will require patients to complete consent forms for the release of information to programs regardless of whether the disclosure is outside or within our own project. Clinicians will be made aware of this requirement at the next regular staff meeting (12/17/2013). The clinical director will perform random quarterly chart audits on discharged patients to ensure compliance with this POC, ongoing. |
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.
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Observations
Based on a review of patient records, the narcotic treatment program failed to ensure the required patient files were transferred in one of two patient records.
The findings included:
Eleven patient records were reviewed October 9, 2013 through October 11, 2013. Two patient records required the program transfer specific patient record documentation to the receiving narcotic treatment program as part of the transfer process. The narcotic treatment program failed to transfer the documentation in record # 6
Patient # 6 was admitted on July 30, 2013, and discharged as a transfer to another narcotic treatment program on October 7, 2013. A consent to release information listing the information to be transferred to the receiving narcotic treatment program was not documented in the record. There was no documentation of the required patient information being transferred to the receiving facility at the time of the review.
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Plan of Correction
The patient referenced was an internal transfer to another Habit OPCO program within the project. Because the patient was transferred within the project, to staff members who worked within the project, the staff members handling the transfer determined that no consent form was required to be completed. To ensure compliance with this deficiency, Habit OPCO staff will require patients to complete consent forms for the release of information to programs regardless of whether the disclosure is outside or within our own project. Clinicians will be made aware of this requirement at the next regular staff meeting (12/17/2013). The clinical director will perform random quarterly chart audits on discharged patients to ensure compliance with this POC, 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 one of two patient records.
The findings included:
Eleven patient records were reviewed October 9, 2013 through October 11, 2013. Two patient records were reviewed for involuntary or therapeutic discharge. One patient record contained documentation of the patient being discharged for reasons other than those listed by regulation.
Patient # 3 was admitted on August 28, 2012 and discharged on April 30, 2013. The patient received a discharge notice on April 2, 2013 that stated the patient was being discharged for failing to follow the treatment plan. The patient was given a compliance agreement on November 2, 2012, as the patient did not complete the required clinical hours for October. The time period of the agreement included November 2, 2012 to January 1, 2013. Clinical hours were documented for 2 hours in November 2012, 1 hour in December 2012, 1.5 hours for January 2013, and no clinical time for February and March 2013. Documentation dated December 26, 2012 stated the patient would attend 1 hour weekly and have dosing restricted with ongoing non-compliance. A consult documented on March 4, 2013, included a plan to place the patient on hold to gain compliance. There was no documentation in the record of holds used nor dosing restrictions. The April 1, 2013, treatment plan update was the first treatment plan to address the area of noncompliance. The facility failed to document efforts were made to retain the patient in the program.
This is a repeat deficiency from the November 8, 2012 on-site inspection.
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Plan of Correction
Habit OPCO recognizes that 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.
Observations. In making a determination to discharge, Habit OPCO will review and ensure that one of the four (4) standards above is applicable. This will be done by the MDT prior to a discharge schedule / medication taper beginning. Effective immediately, all notices of intent to taper will be sent to the MDT. The nurse manager will ensure that no order is posted to begin a medication taper for an involuntary discharge unless the MDT (multidisciplinary team) has signed off on the taper. |
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.
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Observations
Based on the review of administrative documentation, the narcotic treatment program failed to provide documentation of incident reports involving incidents with potential for negative community reaction to the Department.
The findings included:
Administrative documentation that included the unusual incident reports was reviewed October 8, 2013. The program had documentation of an incident on March 12, 2013, that noted a 911 contact for patient medical issues which involved the arrival of emergency personnel. Another incident, dated January 7, 2013, included the involvement of local police.
The unusual incidents were not reported to the Department.
The process was discussed with the clinical director who acknowledged documentation was not sent.
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Plan of Correction
During the October 2013 Monthly Staff meeting this matter was presented and addressed by the Clinical Director. As part of ongoing annual training for all personnel, this will become part of the process and identified during supervisory sessions conducted. Additionally, through this audit process the clarification of this regulation §715.28(c)(1-5) was clarified by the auditor to the Clinical Director. It is understood and will be standard practice that any such unusual incidents are reported accordingly within 48 hours to the DDAP office utilizing the States Unusual Incident Report form. |