INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and inspection conducted for the approval to use a narcotic agent, specifically Buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on May 5, 2014 to May 8, 2014, by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the findings of the on-site inspection, Marworth 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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705.6 (1) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(1) Provide bathrooms to accommodate staff, residents and other users of the facility.
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Observations
Based on observation during the physical plant inspection, the facility failed to ensure that the hot water temperature did not exceed 120 F.
The findings included:
The physical plant inspection took place on May 6. 2014, at approximately 1 p.m. The water temperature was tested in a bathroom on the residential second floor in the Family Center building. The temperature read 130 F.
The findings were reviewed and confirmed by the director of quality improvement.
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Plan of Correction
The maintenance staff will take water temperatures twice weekly in rooms 6 and 10 at random times of the day,effective May13,2014, for a six month period of time to verify water temp is under 120 degrees. Temps will be recorded in a log maintained bt maintenance supervisor.Water temp was lowered to below 120 degrees during the licensing survey. |
709.81(b)(3)(i) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of partial hospitalization client records, the facility failed to document the clients' medical, drug and alcohol, personal history, psychosocial evaluation at intake in one of four partial hospitalization client records reviewed.
The findings include:
Four partial hospitalization client records were reviewed for intake documentation on May 6, 2014. The facility failed to document the client ' s histories and psychosocial evaluation in one of four records, specifically record # 13.
Client #13 was admitted into the partial hospitalization program on January 27, 2014 and stepped down to outpatient treatment on February 12, 2014. As of the date of inspection there was no documentation of an updated client history or psychosocial evaluation for client #13.
The findings were reviewed with and confirmed by the counseling coordinator, director of quality assurance and project director during the exit interview.
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Plan of Correction
For clients stepping down into the partial hospital program from the Marworth residential program, a template will be developed by Marworth IT coordinator, in consultation with Outpatient Coordinator,to capture updated client history and psychosocial evaluation. Template will be developed by May 20, 2014 training of counselors will be completed by May 23,2014. For client noted in this citation, they are no longer active in this level of care and the record is closed.
Outpatient Coordinator will monitor compliance with a random sample of records, but no less than 15 charts per quarter for two quarters. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the facility failed to obtain an informed, voluntary, written consent prior to the administration of a narcotic agent in one of four records.
The findings included:
Twenty-two patient records were reviewed during the on-site visit. Four patient records were reviewed for the completion of an informed, voluntary written consent prior to the administration of a narcotic agent. The facility failed to document the completion of an informed, voluntary, written consent prior to the administration of a narcotic agent in patient record # 2.
Patient # 2 was admitted into treatment on May 1, 2014. The patient received their initial dose of Suboxone on May 2, 2014, at 6:21 p.m. There was no documentation of an informed, voluntary written consent prior to the administration of a narcotic agent in patient record # 2 at the time of the review.
The findings were reviewed and confirmed by the Medical Director.
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Plan of Correction
The Medical Director, in consultation with Marworth IT oordinator, is developing a "check box" on the Medication Administration Record (MAR).
Whenchecked the box will confirm signed, informed consent. The Check box will be developed and implemented with all training completed on its use by May 23, 2014.
Client #2 had the informed consent completed before the licensing survey was completed.
The medical director will monitor compliance with a review of 10 records per quarter for two quarters. |
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 complete an initial drug screen urinalysis prior to the administration of a narcotic agent, in one of four records.
The findings included:
Twenty-two patient records were reviewed during the on-site visit. Four patient records were reviewed for the completion of an initial drug screen urinalysis prior to the administration of a narcotic agent. The facility failed to document the completion of an initial drug screen urinalysis prior to the administration of a narcotic agent in patient record # 2.
Patient # 2 was admitted into treatment on May 1, 2014. The patient received their initial dose of Suboxone on May 2, 2014, at 6:21 p.m. There was no documentation of an initial drug screen urinalysis prior to the administration of a narcotic agent in patient record # 2 at the time of the review.
The findings were reviewed and confirmed by the Medical Director.
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Plan of Correction
The Medical Director, in consultation with Marworth IT oordinator, is developing a "check box" on the Medication Administration Record (MAR).
When checked the box will confirm an initial drug screen urinalysis. The Check box will be developed and implemented with all training completed on its use by May 23, 2014.
Client #2 has completed his detox as of this writing and the opportunity to confirm original opiate use is passed.
The medical director will monitor compliance of the check box with a review of 10 records per quarter for two quarters. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document the consultation between the narcotic treatment physician determining the initial dose and the narcotic treatment physician performing the physical examination in one of one record.
The findings included:
Twenty-two patient records were reviewed during the on-site visit. In patient record # 3, the narcotic treatment physician determining the initial dose failed to document the consultation with the physician completing the physical examination.
The findings were reviewed and confirmed by the director of quality improvement.
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Plan of Correction
Upon further review of patient record #3, there was a consult over the phone between the prescribing physician and the PA who completed the physical exam. The PA failed to document the phone consultation in the record.
There was a subsequent consult with another physician and the PA, which was documented around the H&P, resulting in the appearance of the prescribing physician not being involved in the consult.
Action plan: all medical staff will be reeducated by the medical director on the importance of accurate, timely and complete recording in the medical record.
The Marworth Quality Improvement Director will review 10 charts over the next quarter to insure documentation of consultation compliance. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on the review of outpatient client records, the facility failed to document the clients' medical, drug and alcohol, and personal history at intake in three of eight outpatient client records reviewed.
The findings include:
Eight outpatient client records requiring documentation of histories were reviewed on May 6-7, 2014. The facility failed to document all or some of the client histories in client records # 18, 21, and 22.
Client #18 was admitted into outpatient treatment on February 17, 2014. As of the date of inspection, there was no documentation of a medical, drug and alcohol, or personal history for client #18.
Client #21 was admitted into outpatient treatment on December 12, 2013 and discharged on March 28, 2014. As of the date of inspection, there was no documentation of an updated medical, drug and alcohol, or personal history for client # 21.
Client #22 was admitted into outpatient treatment on December 16, 2013 and discharged on February 4, 2014. As of the date of inspection, there was no documentation of an updated medical, drug and alcohol, or personal history for client # 22.
The findings were reviewed with and confirmed by the counseling coordinator, director of quality assurance and project director during the exit interview.
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Plan of Correction
For clients stepping down into the outpatient program from the Marworth partial hospital program, a template will be developed by Marworth IT coordinator, in consultation with Outpatient Coordinator,to capture updated client history. Template will be developed by May 20, 2014 training of counselors will be completed by May 23,2014. For clients noted in this citation, two are no longer active in this level of care and the one record (#18)will receive an addendum.
Outpatient Coordinator will monitor compliance with a random sample of records, but no less than 15 charts per quarter for two quarters.
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709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of outpatient client records, the facility failed to document a psychosocial evaluation at intake in seven of eight outpatient client records reviewed.
The findings include:
Eight outpatient client records requiring documentation of a psychosocial evaluation were reviewed on May 6-7, 2014. The facility failed to document a psychosocial evaluation at intake in client records # 16, 17, 18, 19, 20, 21, and 22.
Client #16 was admitted into outpatient treatment on December 23, 2013. As of the date of inspection, there was no documentation of psychosocial evaluation for client #16.
Client #17 was admitted into outpatient treatment on October 18, 2013. A psychosocial evaluation had not been documented until April 17, 2014 for client #17.
Client #18 was admitted into outpatient treatment on February 17, 2014. As of the date of inspection, there was no documentation of psychosocial evaluation for client #18.
Client #19 was admitted into outpatient treatment on January 9, 2014 and discharged on February 14, 2014. As of the date of inspection, there was no documentation of psychosocial evaluation for client #19.
Client #20 was admitted into outpatient treatment on January 6, 2014 and discharged on March 21, 2014. As of the date of inspection, there was no documentation of psychosocial evaluation for client #20.
Client #21 was admitted into outpatient treatment on December 12, 2013 and discharged on March 28, 2014. As of the date of inspection, there was no documentation of psychosocial evaluation for client # 21.
Client #22 was admitted into outpatient treatment on December 16, 2013 and discharged on February 4, 2014. As of the date of inspection, there was no documentation of a psychosocial evaluation for client # 22.
The findings were reviewed with and confirmed by the counseling coordinator, director of quality assurance and project director during the exit interview.
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Plan of Correction
For clients stepping down into the outpatient program from the Marworth partial hospital program, a template will be developed by Marworth IT coordinator, in consultation with Outpatient Coordinator,to capture updated psychosocial evaluation. Template will be developed by May 20, 2014 training of counselors will be completed by May 23,2014. For clients noted in this citation, client 19, 20, 21 and 22 are no longer active in this level of care and the records are closed.Clients 16, 17, and 18 will receive addendums by May23, 2014.
Outpatient Coordinator will monitor compliance with a random sample of records, but no less than 15 charts per quarter for two quarters. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of outpatient client records, the facility failed to document treatment plans to include proposed types of supportive services in five of eight outpatient client records.
The findings include:
Eight outpatient client records were reviewed for comprehensive treatment plans, which included support services on May 6-7, 2014. Five of eight outpatient client records lacked documentation of a treatment plan that included a proposed type of support service, specifically client records # 15, 17, 18, 20, and 22.
The comprehensive treatment plan for client #15 was documented on December 20, 2013; however it did not include a proposed type of support service for client #15.
The comprehensive treatment plan for client #17 was documented on November 8, 2013; however it did not include a proposed type of support service for client #17.
The comprehensive treatment plan for client #18 was documented on February 27, 2014; however it did not include a proposed type of support service for client #18.
The comprehensive treatment plan for client #20 was documented on January 13, 2014; however it did not include a proposed type of support service for client #20.
The comprehensive treatment plan for client #22 was documented on December 20, 2013; however it did not include a proposed type of support service for client #22.
The findings were reviewed with and confirmed by the counseling coordinator, director of quality assurance and project director during the exit interview.
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Plan of Correction
The outpatient staff will be educated to include support services on the treatment plans by the Outpatient Coordinator.Coordinator will monitor compliance through monthly treatment plan reviews. An addendum will be completed on 15,17, and 18 by May 23, 2014. Clients 20 and 22 are discharged and their records are closed. |