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 8-10, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Rhd Montgomery County Methadone Center 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 October 5, 2010.
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Plan of Correction
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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 record documentation, the facility failed to ensure the physician documentation in the patient record of the rationale for granting take home medication in four of five patient records.
The findings include:
Twenty four patient records were reviewed on September 8-10, 2010. Five patient records were reviewed for take home medication documentation that included the physician rationale for ordering take-home privileges.
Patient # 4 received take home privileges that included split doses. There was no rationale documented in patient # 4's record that addressed the patient's take-home status.
Patient # 6 was admitted July 25, 2007. The patient was granted 6 day take-home status as of August 13, 2010. The only documentation by the physician was that the patient "earned take-home."
Patient # 10 was granted take home privileges May 18, 2010. The only documentation by the physician was that the patient "earned take-home." This patient had take home privileges rescinded June 25, 2010.
Patient # 13 was granted her first take home bottle May 14, 2010. The only documentation by the physician was that the patient "earned take-home."
None of these patient records specified a rationale for take-home privileges.
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Plan of Correction
A clinical meeting was held on 9/23/10 between the Medical Director and the Program Director to review the proper documentation by the Medical Director for documenting the rationale specific to Take Home Bottle Priveleges. The Medical Director, the Physician"s Assistant, the Clinical Supervisor and the Program Director will revise the medical form to accomodate proper documentation by the physician and the Program Director will monitor for compliance. Target Date 10/15/2010 |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on the review of patient records, the facility failed to transfer all required patient files in three of four patient records.
The findings include:
Twenty-four patient records were reviewed September 8-10, 2010. Four patient records required the transfer of specific patient documentation to the receiving narcotic treatment facility. Three patient records contained consents to release forms signed by the patient restricting what files could be released to the receiving treatment programs.
Patient records # 9, 14 and 17 contained consents limiting the release of the patient files to those areas restricted under 4 PA Code 255.5, not allowing for all of the patient files required to be transferred.
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Plan of Correction
A clinical meeting was held on 9/23/10 for MCMC Clinical staff to review required releases needed for transfer of patients to other NTP's. Proper releases of information forms were revised and reviewed for documentation by the Clinical Supervisor to ensure that all transfers are in compliance with 715.20 licensure standards. The clinical supervisor will monitor each case for adherence and completeness.
Completed 9/23/10 |
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 all of the required information in four of eight patient records, or complete within the required time frame in three of eight patient records.
The findings include:
Twenty-four patient records were reviewed September 8-10, 2010. Eight patient records were reviewed for complete discharge summaries.
Patient records # 7, 8, 14, 15, 16 and 17 did not document the reasons the patients entered into treatment, including only a statement of their drug history.
Patient records # 7, 8, 14, 15 and 17 did not document a response to the treatment process, documentation included the discharge reason and/or attendance of the patient.
Patient records # 8, 14 and 15 did not document all services offered to the patient during the course of their treatment.
Patient records # 7 and 9 contained discharge summaries that were completed more than seven days after discharge. Record # 7 was discharged August 2, 2010 and the discharge summary was completed August 13, 2010, eleven days late. Record # 9 was discharged January 14, 2010 and the discharge summary was completed January 27, 2010, thirteen days late.
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Plan of Correction
A clinical meeting was held on 9/23/10 for MCMC Clinical staff by the Clinical Supervisor to review required discharge information to include all all necessary information to be documented to comply with 715.23 licensure standards. Clinical Supervisor will monitor for compliance. Target Date: Completed |
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 patient records, the facility failed to document behavioral steps to complete the treatment goals in four of four patient records.
The findings include:
Twenty four patient records were reviewed September 8-10, 2010. Four patient records were reviewed for treatment plan documentation compliance.
Patient records # 4, 5, 7 and 12 had a documented treatment plan that contained behavioral steps for the patients to complete that did not pertain to the stated goal. The specific goal being addressed was to recover from opiate dependency, but the action step stated the patient was to pay their respective financial obligation to the facility even though there was no indication that finances were problematic for the patient.
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Plan of Correction
A Clinical Meeting was held on 9/23/10 by the clincal supervisor with the clinical staff to review treatment planning and the proper documentation of behavioral steps to complete treatment planning goals. Clinical Supervisor will monitor treatment plans ongoing for compliance. Completed 9/23/10 |
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
Based on a review of patient records and an interview with the clinical supervisor, the facility failed to document all components required for an exception in two of five patient records.
The findings include:
Twenty-four patient records were reviewed on September 8-10, 2010. Five patient records were reviewed for documentation pertaining to a previously approved exception. The facility failed to comply with the conditions of the exception granted by the Department regarding thirteen day take-home privileges. Patients on a thirteen day status must have quarterly call backs (an unscheduled return to the facility within 24 hours of notification) that includes an inventory of the patient's remaining take home supply, a documented review of the patient's status, and drug testing or methadone plasma levels. The facility failed to conduct quarterly call backs for patients # 1 and 2. In addition, the documentation of Department approval was not in the patient records for patients # 2 and 14.
Patient # 1 was admitted into treatment May 25, 2005. The facility received a Department approved exception for this patient to receive a thirteen day take-home status. The last documented call back with all required components was April 6, 2010.
Patient # 2 was admitted into treatment November 18, 1998. The Department approval exception for this patient to receive a thirteen day take-home status was not in patient record. The last documented call back with all required components was April 22, 2010.
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Plan of Correction
A clinical meeting was held on 9/23/10 between the clinical supervisor and MCMC staff to review the necessary procedures regarding Take Home Privleges and exceptions to include quarterly unscheduled callbacks to inventory take home supplies, documention of reviews of the patient staus and drug testing or methadone plasma levels. All of this is to be documented in all patient charts including any exceptions.Clinical Supervisor will monitor for completeness. Completed 9/23/10 |