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 July 16 through July 18, 2012 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 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.
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Plan of Correction
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715.6(a)(3)(i) LICENSURE Physician staffing
(a) A narcotic treatment program shall designate a medical director to assume responsibility for administering all medical services performed by the narcotic treatment program.
(3) The medical director 's responsibilities include the following:
(i) Supervision of narcotic treatment physicians.
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Observations
Based on the review of employee records and administrative documentation, the facility failed to document how the medical director was made aware of his responsibility to supervise other narcotic treatment physicians.
The findings include:
The personnel record of the medical director was reviewed on July 16, 2012. Documentation was requested from the facility director and the Director of Narcotic Treatment Programs, verifying that the medical director was made aware of his responsibilities to provide supervision of the other narcotic treatment physicians employed at the facility. The facility was unable to provide the requested information.
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Plan of Correction
Medical Director was a locum tenem and as such did not sign a specific job description.
Human Resource's reviewed Medical Director's responsibilities with him on 7.17.12 and Medical Director signed form acknowledging awareness of his job responsibilities.
Human resources will ensure that job descriptions for all staff are reviewed and signed at the start of employment. This will include locum tenems.
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715.6(a)(3)(ii) LICENSURE Physician staffing
(a) A narcotic treatment program shall designate a medical director to assume responsibility for administering all medical services performed by the narcotic treatment program.
(3) The medical director 's responsibilities include the following:
(ii) Supervision of licensed practical nurses if the narcotic treatment program does not employ a registered nurse to supervise the nursing staff. In addition, the medical director in these instances shall ensure that licensed practical nurses adhere to written protocols for dispensing and administration of medication.
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Observations
Based on the review of employee records and administrative documentation, the facility failed to document how the medical director was made aware of his responsibility to supervise licensed practical nurses if the narcotic treatment program does not employ a registered nurse to supervise the nursing staff.
The findings include:
The personnel record of the medical director was reviewed on July 16, 2012. Documentation was requested from the facility director and and the Director of Narcotic Treatment Programs verifying that the medical director was made aware of his responsibilities to provide supervision to licensed practical nurses if the treatment program does not employ a registered nurse to supervise the nursing staff. The facility was unable to provide the requested information
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Plan of Correction
Medical Director was a locum tenem and as such did not sign a specific job description.
Human Resource's reviewed Medical Director's responsibilities with him on 7.17.12. Medical Director signed form acknowledging awareness of his job responsibilities.
Human resources will ensure that job descriptions for all staff are reviewed and signed at least at the start of employment. This will include locum tenems.
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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 dependency in one of six patient records.
The findings include:
Eighteen patient records were reviewed July 16-18, 2011. Six patient records were reviewed for physician documentation of the basis for determining current and one year history of dependency.
Patient # 7 was admitted July 3, 2012. This patient had been treated previously and was involuntarily discharged from the program in December 2011. At the time of the admission, the patient was not dependent for a year prior to the last admission. The physician failed to document in the patient record his justification for admission into the program. He also failed to submit an exception request to the Department with justification for admitting the patient without being dependent for one year prior to admission for maintenance treatment.
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Plan of Correction
Nursing, Narcotic Treatment Physician (NTP) and Program Director reviewed policies and regulations regarding completing appropriate documentation for readmission of previously discharged clients on 7.19.12.
NTP will ensure client is currently physiologically dependent for at least one year prior to admission and maintain appropriate documentation in patient's medical chart.
Director of Nursing (DON) and Program Director will ensure compliance through random monthly chart audits for a period of 3 months or until compliance has been achieved.
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715.9(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
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Observations
Based on the review of patient records, the facility failed to contact the previous narcotic treatment facility for the patient's treatment history in one of one patient record reviewed.
The findings include:
Eighteen patient records were reviewed July 16-18, 2012. One patient record required contacting the prior narcotic treatment facility for the previous treatment history that was reported by the patient.
Patient record # 7 contained documentation that the patient had received narcotic treatment services previously at other narcotic treatment programs. The facility failed to document an attempt to obtain the patient's prior treatment history from the previously attended narcotic treatment facility.
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Plan of Correction
On 7.19.12, Program Director reviewed policy and procedures with counselors and nursing pertaining to obtaining necessary records from previous facilities regarding a client's treatment history.
Counselor will be responsible faxing release to the previous provider and document in client chart the results of the request. The fax receipt will be maintained in the client chart.
Program Director will ensure compliance with regulation through documentation of monthly random chart audits. Findings from each audit will be addressed by the Program Director with the assigned counselor to ensure counselor demonstrates a complete understanding of the expectation.
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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).
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Observations
Based on a review of patient records, the narcotic treatment program failed to secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 and 709.28. The patient records failed to contain the required information on the consent to release forms in four of eight patient records. Additionally, the facility documented a consent to release form that exceeded the parameters of 4 Pa. Code 255.5.
The findings include:
Eighteen patient records were reviewed July 16-18, 2012, eight were reviewed for content of the consent to release information provided in the patient records.
Patient record # 5 contained documentation that indicated the funding source was contacted prior to obtaining a consent to release information from the patient. The funding source was contacted on June 18, 2012. The consent to release was not signed until June 19, 2012. This record also contained a consent to release form that failed to document what was allowed to be released to this agency. The release form had "other" checked, but failed to specify what was to be released. The patient also signed a blank consent to release form that failed to indicate who the release was for and what was to be released.
Patient record # 6 had a consent to release form signed that failed to document whether the patient was offered a copy of the consent. The patient record contained no information that the patient was offered a copy of the consent.
Patient record # 8 contained nine consent to release forms signed by the patient that failed to document whether the patient was offered a copy. The patient also signed a blank consent to release form on April 20, 2012. The release failed to indicate who the release was for and what was to be released. The record also contained documentation that was released to a funding source prior to having a consent to release signed. Documentation was released to the funding source on April 20, 2012. As of the date of inspection, the facility had failed to obtain a release for the funding source.
Patient record # 9 contained two consents to release forms signed on 7/13/2012 that failed to document whether the patient was offered a copy. The patient record contained no information that the patient was offered a copy of the consent. Additionally, the record contained a consent to release for an agency that exceeded 4 Pa. Code 255.5. The consent allowed for the release of the aftercare plan and the discharge summary.
These areas were reviewed with the facility director and were not disputed.
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Plan of Correction
The program received revised consents for releasing substance abuse information on 7.23.12 from the VP of Clinical Services.
The revised forms were reviewed with and distributed to all clinical staff on 8.8.12.
Program Director will ensure compliance on the use of the correct forms and release of permitted information through monthly random chart audits.
The Corporate Compliance Officer will conduct quarterly compliance audits to further ensure adherence.
Clinical staff that were identified as being deficient will re-attend DDAP approved Confidentiality training at the next available and convenient offering.
Training attendance will be monitored by Human Resources through quarterly personnel review.
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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.
The findings include:
Eighteen patient records were reviewed on July 16-18, 2012. Seven patient records were reviewed for documentation from the narcotic treatment physician's review of the patient's therapeutic dosage level. Two of seven records failed to include documentation that the narcotic treatment physician reviewed the patient's dosage level at least twice a year, specifically patient records # 2 and 3.
Patient record #2 revealed the narcotic treatment physician conducted a dosage review on June 24, 2011. This was the only dose review documented in the record record for 2011.
Patient record # 3 revealed the narcotic treatment physician conducted a dosage review on December 27, 2011. This was the only dose review documented in the record for 2011.
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Plan of Correction
Medical Director to review regulations, policy and procedures and best practice principles regarding methadone maintenance with NTP by 9.18.12.
Medical Team has revamped internal processes on 7.23.12 to ensure 6 month reviews are occurring and documented according to regulation.
Medical Team will conduct random chart reviews on a monthly basis and submit results to DON for review. DON will ensure follow-up and compliance is maintained.
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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 the review of patient records, the facility failed to ensure the physician documented the rationale for granting take home medication in two of three patient records.
The findings include:
Eighteen patient records were reviewed on July 16-18, 2012. Three patient records were reviewed for take home medication documentation. Per regulation, the narcotic treatment physician shall document in the patient record the rationale for permitting take home medication. Patient records # 1 and 2 did not include documentation of the physician's rationale for granting the take home medication.
Patient record # 1 contained documentation on June 27, 2012 that take home medications was "approved" by the physician. The physician failed to document his rationale for granting the take home medication.
Patient record #2 contained documentation that the narcotic treatment physician approved four take home bottles of medication on May 30, 2012, July 3, 2012, and July 11, 2012. The narcotic treatment physician failed to document his rationale for granting take home medications.
These findings were discussed with the facility director and were not disputed.
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Plan of Correction
Medical Director to review with the NTP regulations, policy and procedures and best practice principles regarding take home privileges and documentation requirements by 9.18.12.
The two identified deficient records will be reviewed and corrected by the NTP by 9.18.12, which will document rational for granting and or rescinding of the home privileges.
The NTP will be responsible for ensuring that rationale for decision to grant take home privileges is recorded on the take request form for all clients making requests.
Medical Team will conduct random chart reviews on a monthly basis and submit results to DON for review. DON will ensure follow-up and 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 review of patient records, the facility failed to ensure that each patient received an average of 2.5 hours of psychotherapy per month during the first two years, 1 hour of which shall be individual psychotherapy in four of eight records reviewed.
The findings include:
Eighteen patient records were reviewed on July 16-18, 2012. Eight patient records were reviewed for the required 2.5 hours of monthly psychotherapy. Patient records # 4, 6, 12 and 14 failed to meet the required hours.
Patient # 4 was admitted April 27, 2011. The average therapy hours were reviewed for the months of April, May, and June of 2012. The patient averaged 1 hour of psychotherapy for the three months reviewed.
Patient # 6 was admitted February 20, 2012. The average therapy hours were reviewed for the months of April, May and June of 2012. The patient averaged 2 hours of psychotherapy for the three months reviewed.
Patient #12 was admitted November 1, 2011. The average therapy hours were reviewed for February, March and April of 2012. The patient averaged 2.33 hours of psychotherapy for the three months reviewed.
Patient # 14 was admitted on August 5, 2010 and discharged on March 3, 2012. The average therapy hours were reviewed for December 2011, January and February of 2012. The patient averaged 1.92 hours of psychotherapy for the three months reviewed.
This is a repeat citation from the methadone monitoring inspection conducted on July 5-7, 2011 and the unannounced follow-up inspection conducted on November 7, 2011.
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Plan of Correction
All counselors will continue to complete individual client tracking grids to record the frequency of service provided.
Program Director will review tracking grids for each staff twice monthly to ensure compliance and communicate findings to counselors during supervision and team meetings.
Counselors will place holds on clients that fail to attend individual and group sessions and document interaction with client regarding this fact.
Counselors will initiate behavioral contracts and discuss problematic clients during clinical team meetings and act according to treatment plan and directive.
Program Director will conduct monthly random chart audits to ensure compliance and the Corporate Compliance Officer will conduct quarterly compliance audits.
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715.20(4) 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.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on the review of patient records, the facility failed to document that it notified the referring facility of the admission and initial dosing of the patient in one of one patient record.
The findings include:
Eighteen patient records were reviewed July 16-18, 2012. One patient record was reviewed for documentation of notification to the referring facility of the admission and dosing of the referred patient.
Patient records # 8 were referred by another narcotic treatment program. The documentation in the record only confirmed that the facility contacted the referring program to determine the patient's last dose the patient received at the referring clinic. The nurse failed to document that they notified the referring clinic of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Plan of Correction
DON to review client transfer policy and documentation requirements with nursing staff by 9.18.12.
Nursing staff will be responsible for faxing release to the previous provider and document in client chart the results of the request. The fax receipt will be maintained in the client chart.
Nursing staff will conduct random chart reviews on a monthly basis and submit results to DON and Program Director demonstrating compliance.
DON will further review and check for accuracy during quarterly audits.
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715.21 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.
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Observations
Based on the review of patient records, the facility failed to document all efforts to retain a patient prior to initiating an involuntary detox.
The findings include:
Patient records were reviewed on July 16-18, 2012. Patient # 15 received an involuntary discharge notification on March 8, 2012. The patient appealed the involuntary notice of termination. There was no documentation in the record that showed the outcome of the appeal. Prior to the facility's written notice of termination to the patient, the medical director issued an order on March 6, 2012 that specified a 10 mg decrease in the patient's methadone per day until the patient's dose reached zero. There were no efforts documented in the record to try to retain the patient.
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Plan of Correction
Program Director to review proper documentation regarding involuntary terminations and the appeal process with medical team, and counselors by 9.10.12.
Involuntary Terminations will be discussed at Clinical Team Meetings to ensure all efforts have been exhausted prior to discharge.
Compliance will be audited by the Program Director through monthly random chart audits and by the Corporate Compliance Officer through quarterly compliance audits.
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715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on the review of patient records, the facility failed to complete the annual physical with re-evaluation by the physician in eight of eight patient records reviewed.
The findings include:
Eighteen patient records were reviewed July 16-18, 2012. Eight patient records were reviewed for the results of an annual physical examination that included an annual re-evaluation by the narcotic treatment physician. The facility failed to document the re-evaluation by the narcotic treatment physician in patient records # 1, 2, 3, 4, 9, 10, 14, and 17.
Patient # 1 was admitted May 14, 2010. The annual physical exam was completed on May 11, 2012 by the Certified Registered Nurse Practitioner (CRNP). The record failed to include a re-evaluation by the physician.
Patient # 2 was admitted March 13, 2009. The annual physical exam was completed on March 16, 2012 by the Certified Registered Nurse Practitioner (CRNP). The record failed to include a re-evaluation by the physician.
Patient # 3 was admitted May 29, 2008. The annual physical exam was completed on May 18, 2012 by the Certified Registered Nurse Practitioner (CRNP). The record failed to include a re-evaluation by the physician.
Patient # 4 was admitted April 27, 2011. The annual physical exam was completed on April 27, 2012 by the Certified Registered Nurse Practitioner (CRNP). The record failed to include a re-evaluation by the physician.
Patient # 9 was admitted April 1, 2009. The annual physical exam was completed on March 2, 2012 by the Certified Registered Nurse Practitioner (CRNP). The record failed to include a re-evaluation by the physician.
Patient # 10 was admitted February 25, 2009. The annual physical exam was completed on February 28, 2012 by the Certified Registered Nurse Practitioner (CRNP). The record failed to include a re-evaluation by the physician.
Patient # 14 was admitted August 5, 2010.. The annual physical exam was completed on August 11, 2011 by the Certified Registered Nurse Practitioner (CRNP). The record failed to include a re-evaluation by the physician.
Patient # 17 was admitted March 29, 2011. The annual physical exam was completed on March 23, 2012 by the Certified Registered Nurse Practitioner (CRNP). The record failed to include a re-evaluation by the physician.
These findings were reviewed with the facility director and Director of Narcotic Treatment Programs on July 17, 2012 and July 18, 2012.
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Plan of Correction
Medical Director will review regulations regarding annual evaluations with NTP and CRNP by 8.30.12.
DON will revise existing annual evaluation form to distinguish between CRNP evaluation and NTP evaluation and review with medical team by 8.30.12.
Medical Team will conduct random chart reviews on a monthly basis and submit to DON and Program Director for review.
DON will ensure compliance is maintained.
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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 narcotic treatment program failed to document psychosocial evaluations in three of eight patient records.
The findings include:
Eighteen patient records were reviewed on July 16-18, 2012. Psychosocial evaluations were reviewed in eight patient records. The narcotic treatment program did not include evaluations in all the required areas in the psychosocial evaluation in patient records # 5, 7, and 8.
Patient record # 5 included a psychosocial evaluation that was completed on July 3, 2012. The psychosocial evaluation did not include the clinician's impressions of the patient support systems and coping mechanism.
Patient record #7 included a psychosocial evaluation that was not signed and dated. The psychosocial evaluation did not include the clinician's impressions of the patient's problems and needs, assets and strengths, support systems, coping mechanisms and conclusions and impressions.
Patient record # 8 included a psychosocial evaluation that was not signed and dated. The psychosocial evaluation did not include the clinician's impression of the patient's problems and needs and support systems.
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Plan of Correction
All counselors will be provided informative packets on Clinical Impressions of the psychosocial evaluation and necessary areas that are required including counselor signature and date. All counselors will sign acknowledgement of understanding by 9.14.12.
Program Director will conduct monthly random chart reviews to ensure compliance. Corporate Compliance Officer will conduct quarterly compliance audits
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715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on a review of patient records, the facility failed to document a complete discharge summary that included the patient's reason for treatment, services offered, response to treatment and client's status upon discharge in six of seven patient records.
The findings include:
Eighteen patient records were reviewed on July 16-18, 2012. Seven records were reviewed for discharge summaries. Four of the seven records did not have discharge summaries that included all required components, specifically records # 2, 4, 13, and 15.
Patient # 2 was admitted on 10/11/2011 and discharged on 4/7/2012. The discharge summary failed to document the patient's response to treatment and the patient's status upon discharge.
Patient # 4 was admitted on 1/30/2012 and discharged on 4/12/2012. The discharge summary failed to document the patient's reasons for treatment and the patient's status upon discharge.
Patient # 13 was admitted on April 11, 2011 and was discharged on March 13, 2012. The record failed to include a discharge summary.
Patient # 15 was admitted on July 13, 2011 and discharged on March 22, 2012. The discharge summary failed to document the services offered to the patient.
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Plan of Correction
All counselors will be provided informative packets on Discharge Summaries that will include specific requirements of a completed discharge summary. All counselors will sign acknowledgement of understanding by 9.14.12.
Program Director will review all discharged clients charts to ensure compliance.
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on the review of patient records, the facility failed to complete annual evaluations in accordance with the regulations in five of seven patient records reviewed.
The findings included:
Eighteen patient records were reviewed July 16-18, 2012. Seven patient records required documentation of an annual clinical review. Three of the five failed to include the date by the counselor's signature. Therefore there was no way to determine when the annual review was completed, specifically in patient records # 1, 3, and 4.
Patient # 1 was admitted on May 14, 2010. The annual evaluation was completed by the counselor, however, the counselor failed to date his/her signature. There was no way to determined when the evaluation was completed.
Patient # 3 was admitted on May 29, 2008. The annual evaluation was completed by the counselor, however, the counselor failed to date his/her signature. There was no way to determined when the evaluation was completed.
Patient # 4 was admitted on April 27, 2011. The annual evaluation was completed by the counselor, however, the counselor failed to date his/her signature. There was no way to determined when the evaluation was completed.
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Plan of Correction
All counselors to review policy and procedures of proper completion of annual evaluations and sign acknowledgement of understanding by 9.10.12.
Program Director will review all counselor generated client annual evaluations upon completion to ensure compliance.
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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 five of eleven patient records.
The findings include:
Eighteen patient records were reviewed on July 16-18, 2012. Treatment plan updates were reviewed in eleven patient records. According to the regulations, treatment plan updates must be reviewed and evaluated at least every sixty days. The narcotic treatment program did not document the treatment plan updates within the required time frames in patient records # 9, 10, 13, 14, and 17.
Patient record # 9 was admitted April 1, 2009. The record contained a treatment plan update on January 27, 2012. The next treatment plan update was due by March 27, 2012. The treatment plan update was not documented until April 23, 2012 (27 days late). The next treatment plan update was due on June 23, 2012. The facility documented the treatment plan update on July 16, 2012 (24 days late).
Patient #10 was admitted on February 25, 2009. The record contained a treatment plan update on December 23, 2011. The next treatment plan update was due on February 23, 2012. The treatment plan update was not documented until March 25, 2012 (one month late).
Patient #13 was admitted on April 11, 2011. The record contained a treatment plan update dated July 12, 2011. The next treatment plan update was due September 12, 2011. The treatment plan update was not documented until November 11, 2011 (2 months late). The next treatment plan update was due January 11, 2012. The treatment plan update was not documented until January 24, 2012 (13 days late).
Patient # 14 was admitted on August 5, 2010. The record contained a treatment plan update dated October 21, 2011. The next treatment plan update was due December 21, 2011. The treatment plan update was not documented until February 7, 2012 (48 days late).
Patient # 17 was admitted on March 29, 2011. The record contained a treatment plan update dated January 2, 2012. The next treatment plan update was due on March 2, 2012. The treatment plan update was not documented until March 29, 2012 (27 days late).
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Plan of Correction
All counselors will be retrained by Corporate Compliance Officer on treatment plan writing, documentation, updates and individual specific goals by 9.25.12.
Program Director and counselors will conduct monthly random chart reviews to ensure compliance. Corporate Compliance Officer will conduct quarterly compliance audits.
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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.
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Observations
Based on a review of the policy and procedure manual and patient records, the facility failed to ensure that verbal medication orders were put in writing and signed with 24 hours thereafter by the prescribing physician, as required by regulations, in three of four patient records.
The findings include:
Eighteen patient records were reviewed on July 16-18, 2012. All verbal medication orders are required to be signed within 24 hours by the prescribing physician. Patient records # 4, 11, and 12 contained documentation of a verbal medication order that was not signed by the prescribing physician within 24 hours.
Patient record # 4 contained verbal orders documented on August 18, 2011 and July 4, 2012 for the nurse to increase the patient's methadone dose. The narcotic treatment physician signed the verbal orders for each entry, however, the narcotic treatment physician failed to date their signature. There was no way to determine whether the verbal order was signed within 24 hours.
Patient record # 11 contained verbal orders that were received by the narcotic treatment physician on July 1, 2012. This order was signed off by the medical director on July 3, 2012. The medical director was not the prescribing physician. The facility failed to have the prescribing narcotic treatment physician sign off on the verbal order within 24 hours. The record also included a verbal order received by the narcotic treatment physician on July 9, 2012. The medical director signed off on this order and failed to date his signature. The medical director was not the prescribing physician. The facility failed to have the prescribing narcotic treatment physician sign the verbal order within 24 hours.
Patient record # 12 had a verbal order that was received by the medical director on November 8, 2011. The medical director signed off on the verbal order but did not date his signature. There was no way to determine whether the verbal order was signed within 24 hours.
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Plan of Correction
Medical Director to review with NTP regulations and policy regarding verbal orders by 8.30.12.
DON to review with medical team policy and procedures regarding verbal orders and ensuring orders are signed off by prescribing physician with 24 hours and signature is dated by 9.1.12.
Medical Team will conduct random chart reviews on a monthly basis and submit to DON and Program Director for review. DON will ensure compliance.
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