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 October 22-24, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Habit OPCO, Inc. - Allentown 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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715.9(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 four of four patient record reviewed.
The findings include:
Twenty four patient records were reviewed October 22-24, 2013. Four patient records required contacting the prior narcotic treatment facility for the previous treatment history the patient reported to have received.
Patient records # 14, 15, 16 and 17 contained documentation the patients had received narcotic treatment services previously at another narcotic treatment program. There was no documentation the facility had attempted to contact the previous narcotic treatment providers for the treatment histories.
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Plan of Correction
The Director of PA Operations discussed the deficiency findings of 715.9(c) with the Clinical Director and Lead Counselor.
As part of our intake process, consents to release information will be signed by patients allowing us to contact their prior treatment provider. The clinician will contact the previous provider requesting documentation on treatment history. Clinician will document the attempt to obtain patient records and all received documents will be placed in the patients charts.
These findings will be discussed with the clinical staff during our scheduled group supervision on November 14, 2013 and a review of regulation 715.9(c) will occur along with instructions for the corrective action. Progress will be monitored by the Clinical Director and Lead Counselor through regularly scheduled supervision and chart reviews.
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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 the review of patient records, the facility failed to ensure all consents to release information was properly completed in five of fifteen patient records reviewed.
The findings include:
Twenty four patient records were reviewed October 22-24, 2013. Fifteen patient records were reviewed specifically for properly completed consents to release information.
Patient record # 8 contained several consents to release information that were not completed in accordance with the regulations. On May 23, 2013 a consent to release information was completed for another treatment provider that was restricted to 4 PA Code 255.5. On September 11, 2013 a consent to release for a governmental agency was initiated that allowed only the treatment status to be released without allowing for the presence in treatment or the nature of the treatment, which was released.
Patient record # 10 contained a consent to release information to another narcotic treatment provider that was not sufficient to cover the information sent. There was also a consent for a governmental agency that was not signed by the patient as required.
Patient record # 13 contained three consents not signed by the patient or a witness.
Patient record # 14 contained two consents to release that were not signed by the patient or the witness.
Patient record # 17 contained documentation of information released that exceed what the consent to release allowed.
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Plan of Correction
Director of PA Operations addressed deficiencies found in regulation 709.28(c) with the Clinical Director and the Lead Clinician, in regards to Confidentiality. Findings will be shared with the clinical staff during the next group supervision scheduled for November 14, 2013 and regulation 709.28(c) will be reviewed.
Training on confidentiality and consent to release information will be arranged and provided to all clinical staff members no later than December 31, 2013. The training will give clinicians insight into regulatory guidelines of 42 CFR 2.22, and will include the restrictions of 4 PA Code 255.5, and the proper completion of consents to release information.
Furthermore, transfer fax sheets will have a check off box to include all documentation sent in accordance with regulation 715.20.
The Clinical Director and Lead Counselor will monitor the accuracy of consents to release patient information through regularly scheduled individual and group supervision, as well as cart reviews paying close attention to consents.
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715.20 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.
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Observations
Based on a review of patient records, the facility failed to ensure the transfer of a patient for continued maintenance within seven days of the patient's request as required.
The findings include:
Twenty four patient records were reviewed October 22-24, 2013. One patient record required the program to initiate a transfer at the request of the patient.
Patient # 10 was admitted May 25, 2012. The patient requested a transfer to another facility on July 3, 2013. The counseling note stated the counselor would not transfer because the counselor thought the patient needed a different level of care. Instead, the patient was given a notice of intent to involuntarily detox the patient.
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Plan of Correction
Director of PA Operations discussed deficiencies found in regulation 715.20 with the Clinical Director and Lead Counselor.
This deficiency was an isolated incident by a clinician who felt the patient needed a higher level of care. The Clinical Director met with the clinician to discuss the deficiency and to review regulation 715.20.
Findings will be shared with the clinical staff during group supervision on November 14, 2013 and a review of regulation 715.20 will occur.
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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 the required patient files in three of three patient records reviewed.
The findings include:
Twenty four patient records were reviewed October 22-24, 2013. Three patient records required the facility transfer specific patient files to the receiving narcotic treatment program as part of the transfer process. There was no documentation of the required patient files being transferred to the receiving facility.
Patient # 9 was discharged as a transfer to another narcotic treatment facility March 29, 2013. There was no documentation the required patient files were transferred to the receiving facility.
Patient # 22 was discharged as a transfer to another narcotic treatment facility October 19, 2013. There was no documentation the required patient files were transferred to the receiving facility.
Patient # 23 was discharged as a transfer to another narcotic treatment facility October 11, 2013. There was no documentation the required patient files were transferred to the receiving facility.
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Plan of Correction
Director of PA Operations discussed deficiencies found in regulation 715.20(1) in regard to patient transfer documentation with the facility Clinical Director and Lead Counselor.
The Clinical Director will implement a fax cover sheet that has all required documents listed in regulation 715.20(1) to be checked off. These fax cover sheets and confirmation page will be placed in the patient chart as proof of compliance.
Regulation 715.20(1) will be reviewed during staff supervision on November 14, 2013 along with the procedure designed to ensure compliance. Furthermore, the clinical team will pay closer attention to this area during scheduled chart reviews.
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715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on the review of patient records, the facility failed to transfer the required patient files in three of three patient records reviewed.
The findings include:
Twenty four patient records were reviewed October 22-24, 2013. Three patient records required the facility transfer specific patient files to the receiving narcotic treatment program as part of the transfer process. There was no documentation of the required patient files being transferred to the receiving facility.
Patient # 9 was discharged as a transfer to another narcotic treatment facility March 29, 2013. There was no documentation the required patient files were transferred to the receiving facility.
Patient # 22 was discharged as a transfer to another narcotic treatment facility October 19, 2013. There was no documentation the required patient files were transferred to the receiving facility.
Patient # 23 was discharged as a transfer to another narcotic treatment facility October 11, 2013. There was no documentation the required patient files were transferred to the receiving facility.
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Plan of Correction
Director of PA Operations discussed deficiencies found in regulation 715.20(3) in regard to patient transfer documentation with the facility Clinical Director and Lead Counselor.
The Clinical Director will implement a fax cover sheet that has all required documents listed in regulation 715.20(3) to be checked off. These fax cover sheets and confirmation page will be placed in the patient chart as proof of compliance.
Regulation 715.20(3) will be reviewed during staff supervision on November 14, 2013 along with the procedure designed to ensure compliance. Furthermore, the clinical team will pay closer attention to this area during scheduled chart reviews.
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715.21(1)(i-iv) 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.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
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Observations
Based on a review of patient handbook and the policy and procedure manual, the facility failed to restrict their policy and procedure on involuntary terminations to those areas specified in the regulations.
The findings include:
A review of the patient handbook on October 22, 2013 revealed that patients were informed they could be terminated for reasons other that those specified by regulations. According to the handbook documentation, patients could be terminated for reasons such as loitering, illicit drug use, funding/insurance issues and nonpayment for treatment services.
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Plan of Correction
The Director of PA Operations discussed the deficiency findings of regulation 715.21(1)(i-iv) with the Clinical Director.
The patient handbook in the PA clinics will be revised to include only regulatory reasons for discharge as outlined in regulation 715.21(1)(i-v). An addendum will be given to patients with the patient handbook informing them of the changes to reasons for involuntary discharge.
Regulation 715.21(1)(i-v) will be reviewed with staff during group supervision on November 14, 2013 along with the procedure of implementing the addendum.
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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 a re-evaluation by the physician in three of seven patient records reviewed.
The findings include:
Twenty four patient records were reviewed October 22-24, 2013. Seven required an annual physical with a re-evaluation by the narcotic treatment physician. Three did not have the annual re-evaluation.
Patient # 3 was admitted October 8, 2010. An annual physical was completed by the narcotic treatment physician September 30, 2013. There was no re-evaluation included in the annual physical as required.
Patient # 10 was admitted May 25, 2012. An annual physical was completed by the narcotic treatment physician May 7, 2013. There was no re-evaluation included in the annual physical as required.
Patient # 20 was admitted February 23, 2012. An annual physical was completed by the narcotic treatment physician February 11, 2013. There was no re-evaluation included in the annual physical as required.
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Plan of Correction
The Director of PA Operations addressed the deficiency found in regulation 715.23(b)(5) with the Nurse Manager and the Clinical and Medical Directors.
The Nurse Manager has included a required field on the annual evaluation forms to be completed by the attending physician. The required field asks for the physician's re-evaluation of patients continued participation in MMTP.
Compliance with this regulation will be monitored by the Medical Director and Nurse Manager.
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715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on a review of patient records, the facility failed to document follow up attempts in four of six patient records reviewed.
The findings include:
Twenty four patient records were reviewed October 22-24, 2013. Six patient records required documentation of an attempt to obtain follow up information.
Patient # 9 was discharged as a transfer March 29, 2013. There was no documentation of a follow up attempt to determine the patient's status within seven days of the transfer appointment as required.
Patient # 10 was discharged July 22, 2013. There was no documentation of a follow up attempt at the time of the inspection.
Patient # 19 was discharged July 23, 2013. There was no documentation of a follow up attempt at the time of the inspection.
Patient # 20 was discharged August 13, 2013. There was no documentation of a follow up attempt at the time of the inspection.
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Plan of Correction
The Director of PA Operations discussed the deficiency findings of regulation 715.23(b)(24) with the facility Clinical Director and Lead Counselor.
The Clinical Director and/or the Lead Counselor will monitor discharges weekly for call backs due using SMART reports. Progress of compliance in reference to timeliness call backs will be discussed during scheduled individual supervision and will gain close attention during chart reviews.
Regulation 715.23(b)(24) will be reviewed with clinical staff during group supervision scheduled for November 14, 2013 and patient records - will be continuously monitored for compliance.
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