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 April 9, 10 and 11, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHD Montgomery Count Methadone Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on May 9, 2008.
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Plan of Correction
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
A review of time sheets provided by the facility director indicated that during the week of January 27, 2008, there was insufficient physician services as the physician's assistant worked 4 hours, the medical director worked 9 hours, and the part-time physician worked 10 for a total of 23 hours, 5 hours less than what was needed based on the patient census for medical coverage for that week.
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Plan of Correction
Program Director will review all Physician scheduled work hours in advance of the work week as well as closely monitor time sheets to ensure that hours were actually worked. This will ensure compliance with required regulations regarding Physician/Client staff ratio coverage. Time Frame: Immediately |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Based on a review of physician hours during the months of January, February, and March, 2008, the facility failed to maintain the required ratio of physician hours to physician extender hours. Specifically, in the thirteen weeks reviewed, the physician worked nine hours in seven of those weeks while the physician's assistant worked twenty hours per week. The physician failed to provide at least one-third of the required physician time.
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Plan of Correction
A meeting will be held by the Program Director with the PA C and the Narcotic Physician to review scheduling of physician services to identify why deficiencies occurred in Jan, Feb and March 2008 and to develope a plan to correct this, specifically, Program Director will review all Physicians scheduled work hours in advance of the work week as well as closely monitor time sheets to ensure that hours were actually worked. This will ensure compliance with required regulations regarding Physician/Client staff ratio coverage. Time Frame: June 6, 2008 |
715.8(1)(vi) LICENSURE Psychosocial Staffing
A narcotic treatment program shall comply with the following staffing ratios as established in Chapter 704 (relating to staffing requirements for drug and alcohol treatment activities):
(vi) Outpatients. The counseling caseload for one FTE counselor in an outpatient narcotic treatment program may not exceed 35 active patients.
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Observations
Following a review of counselor caseloads provided by the facility director, the facility failed to maintain the required 35 patients to one counselor ratio. Counselor #10 was assigned a caseload of 20 patients while working 20 hours per week yielding an overall ratio of 40:1.
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Plan of Correction
Counselor #10's caseload has been reduced to the required counselor/client ratio and Clinical Supervisor under the supervision of the Program Director will monitor counselors' caseloads to ensure that this does not happen again. Time Frame: Completed |
715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
A review of fifteen randomly selected patient records revealed that the facility failed to provide documentation verifying the individual's identity, to include proof of name, date of birth and address in 4 of 15 patient records; specifically #1, 3, 21, and 23.
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Plan of Correction
Program Director will meet with Intake Coordinator to go over requirements for admission to include obtaining proper documentation of name, date of birth and address and Program Coordinator will check all new admissions to insure that this documenatation was obtained and filed in client records. Intake Coordinator will contact Clients #1, 3, 21 and 23 to obtain needed information and file in client records. Time Frame: June 6, 2008 |
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 observation and staff interview, the facility failed to maintain the security of patient records; specifically, the file cabinets used to store patient records were unlocked as were the the doors to the file room permitting unrestricted access to patient records.
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Plan of Correction
Discharge files will be moved from present location to another room which is remote and has only one lock. Program Director will keep key in her office and room will be locked at all times. Staff will also be instricted on confidentiality of files and need to protect client information. Time Frame:
7/1/08 |
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 fifteen patient records, the facility failed to ensure the completion of a monthly random drug-screening urinalysis in one record. Specifically, patient record # 3 did not contain urine drug screening results for January and March, 2008.
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Plan of Correction
Program Director will ensure that all patients are given a monthly urine drug screen and an Inservice will be held to require that each counselor monitor their caseload for compliance and to inform Director of UDS results for all patients on a monthly basis.In the event that a Urine unable to be obtained, an oral swab will be used as per program exception. Client #3 could not medically provide a specimen and will be given oral swabs as needed. Time Frame: June 6, 2008 |
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 random review of fifteen patient records, the facility failed to document that the physician reviewed the methadone dose levels for patients # 7 and 13 at least twice during the past year.
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Plan of Correction
Procedure will be put in place for Nursing to generate services due list and schedule patients at least twice per year with the Physicians to do medication checks and review for appropriate medication dose levels.Narcotic Physician will monitor that this happens and to ensure that this deficiency does not occur again. Program Director will oversee this procedure. Time Frame: 6/6/08 |
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
Following a review of facility policy and procedure and staff interviews, the facility failed to ensure that the physician is responsible to determine the specific dosing needs of the patients; specifically, the facility maintained a policy of "standing physician orders" for patients who are returning to the facility following a three to six day lapse in services. These orders, per policy, have permitted patients to be dosed following a lapse in treatment without being first assessed by the physician for the proper dosage.
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Plan of Correction
A meeting will be held with the Narcotic Program Physician, the Physician's Assistant and the Program Director to ensure that the Narcotic Physician alone determines the specific dosing needs of the patients. Standing Orders have been discontinued and the Narcotic Physician must assess each patient as for proper dosing following a patient lapse to the facility. Medical Director will be responsible to ensure that this corrective action plan is implemented and Program Director will oversee this procedure. Time Frame: Completed |
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 fifteen records the facility failed to document that the physician made determination regarding take-home medications, specifically the physician was signing all take-home determination documentation with the phrase "earned take home" with no additional information included to identify reasons for ordering take-home medications.
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Plan of Correction
A meeting will be held with the Narcotic Program Physician, the Physician's Assistant and the Program Director to review process of awarding Take Home Medications and that it is the sole responsibility of the Medical Director to determine whether a person is eligible for such.Case Consults and counselor's input will be given to the Medical Director to give additional clinical information that the Medical Director needs to make this determination.Program Director will oversee that this is implemented and to ensure that this deficiency does not occur again. Time Frame:6/6/08 |
715.16(c) LICENSURE Take-home privileges
(c) A narcotic treatment program shall require a patient to come to the narcotic treatment program for observation daily or at least 6 days a week for comprehensive maintenance treatment, unless a patient is permitted to receive take-home medication as follows:
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Observations
The facility must address the need to provide methadone maintenance seven days a week for those patients who do not qualify for take-home privileges. This need may be addressed by having the facility open seven days per week or securing courtesy dosing for patients who do not qualify for take-home privileges.
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Plan of Correction
MCMC will begin to open 7 days per week and will ask for exception for holidays with a start date of September 2, 2008. All staffing issues will be finalized by this time if not sooner and if sooner, MCMC will open at an earlier date than September 2, 2008. |
715.17(c)(6)(i-iv) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(6) Inventories. A narcotic treatment program shall conduct monthly inventories of agents and other controlled substances stored. Each inventory record shall include:
(i) The date the inventory was conducted.
(ii) The time of day it was conducted.
(iii) The name and amount of each product on hand at the time of the inventory.
(iv) The name of the individual conducting the inventory.
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Observations
The facility failed to develop a policy and procedures that were consistent with facility practice. Specifically, the policy stated that inventories would be performed quarterly, however, the inventories were actually performed daily by the nurses. According to the standards, inventories must be performed at least monthly. Facility policy and practice must be congruent.
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Plan of Correction
Facility policy will be amended by the Program Director and the nursing staff will be advised that inventories will be performed daily as per our Computer system which performs this function daily upon system close for the day. Charge Nurse will be responsible for the quarterly reporting of inventories. Program Director will monitor that this procedure is followed and that this deficiency does not occur again. Program Director will review quarterly inventories and the daily inventory produced by the computer and verified by the nursing staff. Time Frame: 6/6/08 |
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 a review of fifteen patient records, the facility exceeded the regulatory reasons that permitted a patient's involuntary termination from treatment. Documentation, signed at admission by the patient, indicated an involuntary termination could occur for non-payment; all records reviewed contained this documentation.
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Plan of Correction
Documentation signed at admission by patients regarding involuntary termination for non payment will be amended by the program director to remove the sentence "If you are delinquent for more than one month, you will be subject to Administrative Discharge".This will bring this in compliance with regulatory standards. Time Frame: 6/5/08 |
715..23(b)(1) LICENSURE Patient records
(b) Each patient file shall include the following information:
(1) A complete personal history.
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Observations
Based on a review of patient records, the facility failed to document a complete personal history in 9 of 15 records, specifically #1, 2, 3, 4, 6, 19, 21, and 23. The personal histories contained either one-word answers with no further clarification or questions left unanswered.
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Plan of Correction
Clinical Staff wil now be completing Psychosocial Histories.An Inservice will be held by the Program Director with the entire Clinical Staff including the Intake Coordinator to review the proper completion of personal histories on the Psychosocial evaluation to give an accurate picture of the client history.Clinical Supervisor will review these histories and monitor for compliance. Time Frame 6/06/08 |
715.23(b)(3) LICENSURE Patient records
(b) Each patient file shall include the following information:
(3) A complete medical history
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Observations
Based on a review of fifteen patient records the facility failed to document a complete medical history as the history did not include family medical information in 5 of 15 records; specifically, patient records # 4, 6, 9, 17, and 21.
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Plan of Correction
Clinical Staff will now be completing Psychosocial Histories.An Inservice will be held by the Program Director with the entire Clinical Staff including the Intake Coordinator to review the proper completion of family medical histories to include family medical history on the Psychosocial evaluation to give an accurate picture of the client history.Clinical Supervisor will monitor for this compliance to ensure that this deficiency does not occur again. Time Frame 6/05/08 |
715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
Based on the review of fifteen patient records, there was no documentation the facility had completed blood serology tests for Syphilis on patients # 6 and 21.
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Plan of Correction
Nursing Staff or PA C will draw blood within two weeks of patient admission including request for syphilis test on all patients. Upon receipt of serology results, Nursing staff/PA C will review these results and file appropriatley in patient record. Charge Nurse will monitor this procedure to ensure that this is in compliance and this deficiency does not happen again. Program Director will oversee this procedure. Time Frame: 6/6/08 |
715.23(b)(11) LICENSURE Patient records
(b) Each patient file shall include the following information:
(11) Counselor notes regarding patient progress and status.
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Observations
Based on a review of 15 patient records, the facility failed to provide the required information regarding the patient's progress and status in the clinical documentation, particularly the group notes for patients # 2, 4, 11, 13, 15, and 17. The Data, Assessment, Plan (DAP) format was utilized which failed to include an assessment of the patient's participation, or lack of, in the group sessions.
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Plan of Correction
A Meeting will be held by the Clinical Supervisor and the Group Therapists to review the necessary required information needed that will ensure that the patient's progress and status is recorded in the clinical documentation. The DAP format will be used and will include the Assessment of client's participation or lack of participation in group. Program Director will Oversee this process. Time Frame: 6/6/08 |
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 review of fifteen patient records, the facility failed to provide an evaluative assessment from the historical data obtained in the personal history that included the counselor's clinical analysis of the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, patient's attitude toward treatment and overall impressions. Instead, the psychosocial evaluations of the patient consisted primarily of the repetition of the history and statements reported by the patient in records 2, 4, 5, 11, and 15.
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Plan of Correction
All Psychosocial Histories will be completed by clinical staff and not the intake coordinator.An Inservice will be held by the Program Director with the entire Clinical Staff to review the proper completion of personal histories to provide an evaluative assessment from the historical data obtained in the personal history that includes the counselor's clinical analysis of the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, patient's attitude toward treatment and overall impressions. Clinical Supervisor will monitor to ensure that this deficiency does not occur again.Program Director will oversee this procedure. Time Frame: 6/6/08 |
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 fifteen patient records, the facility failed to document a discharge summary in 1 of 6 records, specifically record # 33.
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Plan of Correction
An Inservice will be held by the Program Director to review policy regarding patient Discharge Summaries for completion and proper filing in patient records. This will be monitored by the Clincial Supervisor to ensure that this deficiency does not occur again by running a monthly discharge list and making sure that all necessary discharg paperwork is completed upon patient discharge. Time Frame: 6/05/08 |
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 the review of 15 patient records, the facility failed to develop treatment plans that contained short term goals with measurable steps. Further, the treatment plans failed to identify support services needed by the patient. Of the the 15 patient records reviewed, patient records # 1, 5, 7, 9, 13, 15, 19, 23 and 27 contained vague, non-specific steps to reach the goals and the time frames were generalized rather than realistically specific to the action step; no patient records support services were documented. Additionally, treatment plans were developed late for patients # 2, 4, and 17.
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Plan of Correction
The Clinical Supervisor will meeet with the staff to go over the new treatment plans which were implemented to insure that short term goals with measurable action steps as well as identification of support services and time frames are specific to the action steps. Clinical Supervisor will read each treatment plan in entirety prior to signing and approving plan. This will ensure that this deficiency will not occur again. Program Director will oversee this procedure. Time Frame: 6/6/08 |
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 a review of 15 patient record, the facility failed to document treatment plan updates based on the patient's progress as it related to the goals stated in the comprehensive treatment plan, specifically patients # 13, 15, 17, 19, and 27. The treatment plan updates failed to address patient specific goals but consisted of short, generalized statements that were sometimes repeated in the documentation of the patient update. In addition, in patient record #2, the update was completed after the required 60 day time frame.
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Plan of Correction
The Clinical Supervisor will meet with staff to review new treatment plan formatto ensure that the treatment plan updates documents that patient's progress as it relates to the goals stated in the comprehensive treatment plan. Clinical Supervisor will read each treatment plan in SMART prior to signing and approving. This will ensure that this deficiency does not occur again. Program director will oversee this procedure. Tiem Frame: 6/6/08 |
715.29(5) LICENSURE Exceptions
A narcotic treatment program is permitted, at the time of application or any time thereafter, to request an exception from a specific regulation.
(5) If the exception relates to a specific patient, the narcotic treatment program shall maintain documentation of the exception in the patient 's record.
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Observations
The facility failed to comply with the conditions of the exception granted by the Division regarding thirteen day take-home privileges. Patients on thirteen day status based must have quarterly call backs (an unscheduled return to the facility within 24 hours) that includes an inventory of patient's remaining take home supply, drug testing or methadone plasma levels and documentation justifying the continued need for the exception. In three of four patient records reviewed, the facility failed to conduct quarterly reviews and call backs for patients #27, 29, and 31.
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Plan of Correction
Clinical Supervisor will enter prompt in SMART computer system to remind counselors about quarterly call backs on all 13 day patients with Take Home Bottle priveleges to include all requirements for the exception to continue. This will be documented and signed off by the Clinical Supervisor and filed in the patient record.Program Director will oversee this procedure to ensure that this deficiency will not occur again. Time Frame: 6/6/08 |