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 September 28-29, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare York Pharmacotherapy 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 and a plan of correction is due on November 4, 2009.
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Plan of Correction
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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 administrative documentation that included policy and procedure manuals, job descriptions and employee contracts, the facility failed to provide for the supervision of the licensed practical nurses (LPN) employed by the facility.
The findings include:
Administrative documentation was reviewed on September 28-29, 2009. The policy and procedure manual did not discuss the responsibility of supervising the licensed practical nursing staff. The signed contract with the medical director did not include the responsibility of supervising any LPN employed by the facility, or the assurance the LPN staff adhere to the written protocols for dispensing and administration.
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Plan of Correction
The contract with the medical director is being revised by the Director of Pharmacotherapy Services, to include the responsibility of supervising the LPN nursing staff. The revised contract will be reviewed and resigned by 11/20/09. Pyramid has a director of nursing for the corporation who supervises all nursing staff. This information will be documented on the questionnaire of future monitoring visits. |
715.6(b)(1-9) LICENSURE Physician Staffing
(b) A narcotic treatment program may employ narcotic treatment physicians to assist the medical director. A narcotic treatment physician 's responsibilities include:
(1) Performing a medical history and physical exam.
(2) Determining diagnosis and determining narcotic dependence.
(3) Reviewing treatment plans.
(4) Determining dosage and all changes in doses.
(5) Ordering take-home privileges.
(6) Discussing cases with the treatment team.
(7) Issuing verbal orders pertaining to patient care.
(8) Assessing coexisting medical and psychiatric disorders.
(9) Treating or making appropriate referrals for treatment of these disorders.
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Observations
Based on the review of administrative documentation that included policy and procedure manuals, job descriptions and employee contracts, the facility failed to document the narcotic treatment physician's responsibilities.
The findings include:
Administrative documentation was reviewed on September 28-29, 2009. The policy and procedure manual did not discuss the responsibilities of the narcotic treatment physician. The signed contract with the medical director did not include the responsibilities of (3) reviewing treatment plans; (5) ordering take home medications; ((6) discussing cases with the treatment team; (7) issuing verbal orders pertaining to patient care; (8) assessing coexisting medical and psychiatric disorders; (9) treating or making appropriate referrals for treatment of these disorders.
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Plan of Correction
The contracts with the physicians are being revised by the Director of Pharmacotherapy Services, to include the specific job duties of the physicians, including reviewing treatment palns, ordering take home medications, discussing cases with the treatment team, issuing verbal orders pertaining to patient care, assessing coexisting medical and psychiatric disorders, and treating or making appropriate referrals for treatment of these disorders. The contracts will be reviewed and resigned by the physicians by 11/20/09. The specific job responsibilities are also being added to the policy and procedure manual. |
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 facility failed to ensure the psychosocial evaluations were a clinical assessment of the historical data collected in 2 of 3 patient records reviewed.
The findings include:
Ten patient records were reviewed on September 28-29, 2009. Three patient records were reviewed for psychosocial evaluations. Patient record # 5 was re-admitted to the facility July 23, 2009. The facility used the evaluation of the previous admission and did not complete a new evaluation. Patient record # 1 contained statements reflecting the observation of the patient at the time of the evaluation and did not reflect an evaluation of the historical data obtained.
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Plan of Correction
Effective 10/6/09, all patients re-admitted to the program are required to have all new paperwork, including a new psychosocial evaluation completed. A psychosocial training was conducted on 10/6/09 with all clinical staff to review evaluation of historical data obtained, clinical assessments, and the new policy on re-admitted patients. Psychosocials will be reviewed weekly in peer monitoring meetings and monthly by the Program Director for evaluation of historical data obtained in the interview process. |
715.23(b)(22) LICENSURE Patient records
(b) Each patient file shall include the following information:
(22) Aftercare plan, if applicable.
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Observations
Based on a review of patient records, the facility failed to document an aftercare plan in 1 of 1 records.
The findings include:
Ten patient records were reviewed on September 28-29, 2009. One record required an aftercare plan or documentation the patient refused.
Record # 8 was discharged as successfully completing treatment April 8, 2009. There was no documentation in the patient record of an aftercare plan being developed, offered or refused.
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Plan of Correction
All clinical staff participated in a training on aftercare planning and documentation of aftercare plans and refusals on 10/20/09. All aftercare plans require documentation of a plan being developed, offered, or refused, this will be monitored in peer review meetings weekly, it has been added to the chart monitoring checklist. This will be reviewed by the Director in monthly chart monitoring. |
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 the review of patient records, the facility failed to include all of the required information in discharge summaries in 5 of 5 patient records reviewed.
The findings include:
Ten patient records were reviewed September 28-29, 2009. Five records required completed discharge summaries. Patient records # 6, 7, 8, 9 and 10 did not contain information pertaining to the reasons patients entered into treatment. Patient records # 6 and 8 did not describe the services offered to the patient and patient records # 9 and 10 did not include all of the services offered and received by the patient according to the clinical documentation in the record. Patient records 6, 8 and 9 did not provide a summary of the patient's progress in treatment, but rather focused on the reason for discharge.
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Plan of Correction
A new discharge summary form that includes all required information, specifically, reason for entering treatment, services offered and received, and a summary of progress was instituted on 10/6/09. All clinical staff participated in a training on the new form on 10/6/09. The proper use of the new form will be monitored in weekly peer reviews of charts. The Director will conduct monthly chart monitoring to review the use of the new form. |
715.23(d)(1) 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.
(1) The treatment plan shall identify the behavioral tasks a patient shall perform to complete each short-term goal.
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Observations
Based on a review of patient records, the facility failed to document the behavioral tasks for the patient to perform to reach the stated goals of the treatment plan in 2 of 3 patient records.
The findings include:
Three patient records were reviewed for treatment plans on September 28-29, 2009. Patient records # 6 and 9 did not include documentation of the action steps for the patient to complete, instead focusing on what the counselor would be doing.
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Plan of Correction
All clinical staff participated in a training on treatment planning on 10/20/09. This training specifically addressed the documentation of action steps, and identifying tasks for patients to meet goals. Review of the treatment plan action steps has been added to the chart monitoring form. Clinical staff will conduct chart monitoring weekly during their peer review meeting. The Director will complete chart monitoring monthly to review compliance with documenting action steps. |
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 facility failed to update the patient's treatment plan as required in 1 of 2 patient records.
The findings include:
Two patient records were reviewed for treatment plan reviews on September 28-29, 2009. Patient record # 6 was admitted in October 2008 and a comprehensive treatment plan developed November 2008. The record thereafter contained new treatment plans in January and March without any discussion of the progress made by the patient on the goals listed on the treatment plans.
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Plan of Correction
All clinical staff reviewed treatment plan update/review expectations during the treatment plan training on 10/20/09. Review of treatment plan updates/reviews is part of clinical monitoring conducted weekly during peer review meetings with clinical staff, and monthly by the Program Director. The counselor who had the documentation issues noted in this deficiency has not worked in this facility since May 2009, and no such deficiencies have been noted in regular chart monitoring since this staffing change. |