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 and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on February 12- 13, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare York Pharmacotherapy Services was found not to be 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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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on the review of clinical documentation, the facility, particularly the physician, failed to accurately document the basis for determining current and one year history of opiate dependency in ten of ten records reviewed.
The findings include:
Twenty-two patient records were reviewed on February 12-13, 2013. Ten patient records were reviewed for physician documentation of the basis for determining current and one year history of dependency. The facility failed to document dependency for one year prior to the admission in patient records # 1, 3, 4, 9, 12, 13, 14, 20, 21, and 22.
Patient # 1 was admitted on January 24, 2013. A review of the patient record revealed that the patient had been in treatment twice in the past year. The patient attended a seven day detoxification program in April 2012 and the patient also received detoxification services and inpatient treatment for 28 days in June of 2012. The patient failed to meet the one year dependency requirement and the facility did not submit an exception request to the Department for this admission
Patient # 4 was readmitted on September 4, 2012. The patient had received buprenorphine services at this program from February 2012 until approximately July 2012. Review of the record revealed the patient had left treatment for approximately a month and then was readmitted to the program. Documentation in the record revealed the patient had not used for three weeks and relapsed. The patient failed to meet the one year dependency requirement and the facility did not submit an exception request to the Department for this admission.
Patient # 12 was admitted on February 23, 2012 and involuntarily terminated on January 3, 2013. The patient was readmitted to the program on January 29, 2013. The patient failed to meet the one year dependency requirement. The facility did not submit an exception request to the Department for this admission.
Patient records # 4, 9, 13, 14, 20, 21, and 22 included documentation that did not clearly identify for each individual patient that they had one year dependency. The information recorded in the record referred to the patient meeting "DSM criteria, history of withdrawal" and general statements that were not individualized per each patient.
This is a repeat citation from the July 16-18, 2012 monitoring review.
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Plan of Correction
Nursing, Narcotic Treatment Physician (NTP), Director of Nursing, Medical Director and Program Director reviewed policies and regulations with Narcotic Treatment Physician (NTP) and Nursing regarding completing appropriate documentation ensuring client is physiologically dependent for at least one year prior to admission.
If NTP determines a client does not meet one year dependency the NTP will complete an exception request and submit to the Department Of Health's Division of Drug and Alcohol for approval. The client will not be admitted until the exception has been approved. The NTP will review each case requiring an exception with the Medical Director.
Director of Nursing and Program Director will ensure compliance through random monthly chart audits.
NT physician will review charts that were identified deficient and document determination of current dependency and evidence of 1 year addiction history by 3.30.13.
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715.10(c) LICENSURE Pregnant patients
(c) Counseling records and other appropriate patients records shall reflect the nature of prenatal support provided by the narcotic treatment program.
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Observations
Based on the review of patient records, the facility failed to document pre-natal support in six of six patient records reviewed.
The findings include:
Twenty-two patient records were on February 12-13, 2013. Six patient records were reviewed for documentation of prenatal support. Patient records # 7, 13, 14, 19, 20, and 21 did not contain any documentation of prenatal support. The facility failed to address the patient's pregnancy in their treatment plan and there was no reference in the clinical record that addressed prenatal support in the patient's progress notes.
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Plan of Correction
Program Director will re-train all counselors on treatment plan writing to ensure the inclusion of rehabilitative services emphasizing pre and post natal supports and services. Training to occur by March 11, 2013.
Program Director and counselors will conduct random monthly chart reviews on pregnant clients to ensure compliance.
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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.
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Observations
Based on a review of patient records, the facility failed to ensure that the patient was initially dosed following the completion of a drug-screen urinalysis in two of seven patient records.
The findings included:
Twenty-two patient records were reviewed on February 12-13, 2013. Seven patient records were reviewed for drug screen urinalysis results prior to a patient's initial dose. Per regulation, a narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter. The facility failed to document the completion of a drug screen urinalysis prior to dosing in patient records # 13 and 20.
Patient # 13 was admitted into treatment on December 6, 2012. Patient # 13 received a dose of 30 mg on December 6, 2012, the same date that the patient had submitted a urine specimen for a drug-screen urinalysis. The results of the urine specimen were not received by the facility until December 7, 2012. This was after the patient's initial dose of methadone.
Patient # 20 was admitted on November 19, 2012. Patient # 20 received a dose of 20 mg on November 19, 2012. Review of the patient record revealed documentation that the patient did not need a urine specimen because she was pregnant. The facility obtained a urine specimen for drug-screen urinalysis on November 20, 2012, after the patient received their initial dose of methadone.
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Plan of Correction
Program Director reviewed policies and regulations regarding conducting initial drug-screening urinalysis for each perspective client prior to initial dose with Nursing and Narcotic Treatment Physician (NTP) on February 25, 2013.
The NTP will not administer initial dose to any client without receiving the initial UDS.
Director of Nursing and Program Director will ensure compliance through random monthly charts audits.
NT physician will document in the 2 identified deficient charts the rational for dosing prior to receiving the UDS results and justification for dosing i.e. confirmed pregnancy. This will occur by 3.30.13.
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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.
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Observations
Based on a review patient records, the narcotic treatment physician failed to document that the dosage levels were reviewed at least twice a year, with each review occurring at least two months apart, to determine the patient's therapeutic dosage in four of eleven patient records reviewed.
The findings include:
Twenty-two patient records were reviewed on February 12-13, 2013. Eleven patient records were reviewed for documentation from the narcotic treatment physician's review of the patient's therapeutic dosage level. Four of eleven records failed to include documentation that the narcotic treatment physician reviewed the patient's dosage level at least twice a year, specifically patient records # 5, 6, 7 and 19.
Patient record #5 revealed the narcotic treatment physician did not conduct semi-annual dosage reviews in 2012.
Patient record #6 revealed the narcotic treatment physician conducted a dosage review on February 28, 2012 at the request of the patient to start a voluntary detox. This was the only dose review documented in the record for 2012.
Patient record # 7 revealed two dose reviews in 2012. One dose review occurred on October 10, 2012 and another on November 17, 2012. These dose reviews were at the request of the patient and were not at least two months apart. There were no other dose review documented for 2012.
Patient record # 19 revealed the narcotic treatment physician did not conducted semi-annual dosage reviews in 2012.
These findings were reviewed with the facility director. This is a repeat citation from the July 16-18, 2012 monitoring review.
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Plan of Correction
Medical Director to review regulations, policy and procedures and best practice principles regarding methadone maintenance with Narcotic Treatment Physician (NTP) by 3/8/13.
Forms have been revised to ensure appropriate documentation regarding review of dose levels is recorded.
Medical Team will conduct random chart reviews on a monthly basis to ensure compliance is maintained.
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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 patient records, the facility failed to ensure each patient received an average of 2.5 hours of psychotherapy per month during the patient's first two years, one hour of which shall be individual psychotherapy in five of thirteen records.
The findings include:
Twenty-two patient records were reviewed February 12-13, 2013. Thirteen patient records were reviewed for the 2.5 hours of monthly psychotherapy during the first two years of treatment. Patient records # 4, 10, 12, 14 and 20 failed to meet the required hours.
Patient # 4 was admitted on September 12, 2012. The average therapy hours were reviewed for the months of November and December of 2012 and January 2013. The patient averaged .66 hours of psychotherapy per month for the three months reviewed.
Patient # 10 was admitted on January 10, 2012 and involuntarily terminated on October 16, 2012. The average therapy hours were reviewed for the months of July, August and September 2012. The patient averaged 1.16 hours of psychotherapy per month for the three months reviewed.
Patient # 12 was admitted on February 23, 2012 and involuntarily terminated on January 3, 2013. The average therapy hours were reviewed for the months of November and December of 2012. The patient averaged 1 hours of psychotherapy per month for the two months reviewed.
Patient # 14 was admitted July 11, 2012. The average therapy hours were reviewed for the months of November and December 2012 and January 2013. The patient averaged 1.5 hours of psychotherapy per month for the three months reviewed.
Patient #20 was admitted November 19, 2012. Following the initial clinical session, there was no clinical documentation until February 6, 2013. This finding would indicate that the patient received no psychotherapy hours during the months of December and January.
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Plan of Correction
All counselors will continue to complete individual client tracking grids to record frequency of service provided.
Counselors and Administrative Assistant will place reminder calls or messages in dosing system for all clients regarding individuals and group sessions. This will occur by 3.29.13
Counselors will continue to initiate behavior contracts and discuss problematic clients during weekly clinical team meetings.
Program Director will ensure compliance through attendance at weekly clinical team meetings and through bi-weekly monitoring of tracking grids. All deficiencies will be discussed and documented with individual counselor through supervision.
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