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 21-22, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Habit Opco, Inc. - Pottstown 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 May 18, 2010.
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Plan of Correction
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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 a review of patient records, the facility failed to maintain the confidentiality of patient information in accordance with 42 CFR and 4 PA Code 255.5 in five of seven patient records.
The findings include:
Twelve patient records were reviewed April 21-22, 2010. Seven patient records were reviewed for the content of signed consents to release information. Five patient records contained documentation of consents to the release information that exceeded 4 PA Code 255.5.
Record # 1 contained a consent to release information to the funding entity to release dosing information and clinical and medical evaluations.
Record # 3 contained a consent to release information to a fire chief allowing the release of prescription modality and verification for the purpose of "housing".
Record # 4 contained a consent to release information to the probation officer allowing the release of dosing information, HIV/AIDS information and clinical and medical evaluations.
Record # 6 contained a consent to release information to the transportation company allowing the release of dosing information. There was a consent to the funding entity allowing the release of dosing verification, HIV/AIDS information and clinical and medical evaluations.
Record # 9 contained consents to release information to the probation officer and a transportation company allowing the release of dosing information.
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Plan of Correction
The Clinical Director, Program Director and Nurse Manager have distributed "dummy" examples of correctly completed Consents to Release Information to all staff. The "dummy" examples covered various categories of Consents. The issue of correct completion of releases was reviewed at the general staff meeting on May 4, 2010, with "dummy" examples reviewed individually, and an additional in-service training to be held in the near future will include this on the agenda.
Beginning on May 10, 2010 and continuing through June 1, 2010, all staff who complete a Consent to Release Information will print out the release and it will be reviewed and cosigned by the respective supervisor, as follows: the Clinical Director will cosign releases completed by counseling staff; the Program Director will cosign releases completed by administrative staff; the Nurse Manager will cosign releases completed by the nursing staff. Any incorrect releases will be rewritten.
For the months of June, July and August, 2010, the Clinical Director, Nurse Manager and Program Director will monitor all releases completed in the SMART system software and any further incorrect releases will be rewritten.
After August, 2010, the Clinical Director will conduct random reviews of Consents, on an ongoing basis, to coincide with random chart reviews. Any further problems identified will be addressed in individual supervision. |
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 that the physician documented in the patient record the rationale for granting take home medication in four of four patient records.
The findings include:
Twelve patient records were reviewed April 21-22, 2010. Four patient records were required to include documentation of take home privileges and were reviewed for take home medication documentation.
Patient records # 7, 8, 9 and 10 did not include documentation of the physician's rationale for granting the take home medication.
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Plan of Correction
The Program Director reviewed the deficiencies with the Medical Director on April 27, 2010, and provided him with copies of the relevant state regulations. The Program Director instructed the Medical Director regarding the proper use of the form and the relevant documentation required in the patient's electronic chart. The standard form for requesting take-home medication has been revised to allow space for the rationale for approving take-homes. Files will be reviewed by the Program Director on a weekly basis for one month, and then on a monthly basis for three months, for a total of four months.
The Clinical Director will review the forms as part of random chart reviews every quarter to ensure proper documentation. The Clinical Director will submit a written report each quarter pertaining to the proper documentation of the rational for take-homes. |
715.17(b) LICENSURE Medication control
(b) A narcotic treatment program shall develop policies and procedures regarding verbal medication orders, including the issuing and receiving of orders, identifying circumstances when orders are appropriate and documenting orders, in accordance with applicable Federal and State statutes and regulations.
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Observations
Based on the review of patient records and discussion with medical staff, the facility failed to ensure the physician signed the documentation of the order within 24 hours after submitting a verbal order in two of two patient records reviewed.
The findings include:
Twelve patient records were reviewed April 21-22, 2010. Two patient records contained documentation of the physician's verbal orders. While the physician did sign these verbal orders, the signatures were not dated within the required 24 hours.
Patient record # 2 contained documentation of multiple verbal orders. Verbal orders were: issued on 1-21-2010 and signed 1-26-2010; issued on 2-12-2010 and signed 2-16-2010; issued on 2-25-2010 and signed 3-2-2010 and on 3-16-2010 a verbal order was issued and signed 3-18-2010.
Patient # 3 contained documentation of multiple verbal orders. A verbal order was issued on 2-11-2010 and was signed on 2-16-2010; issued on 3-16-2010 and was signed 3-18-2010; and issued on 4-8-2010 and was signed on 4-10-2010.
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Plan of Correction
The Program Director consulted with the Information Technology staff of Habit OPCO regarding the deficiency and the procedure for obtaining the physician's signature within 24 hours of a verbal order. The Information Technology staff provided the physician with software to be installed on the physician's home computer that will allow him to submit a digital signature when issuing a verbal order. If any problems arise with the use of the home computer, the physician understands that he will need to come into the facility to hand-sign verbal orders within 24 hours. The physician has added weekend hours to his schedule to address this possibility.
The Nurse Manager will review and monitor compliance on a bi-weekly basis for two months, and then on a monthly basis for four months, for a total of six months. Any issues of lateness will be reported to the Program Director immediately, and the Program Director will address these with the physician within 48 hours. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment in three of four patient records.
The findings include:
Twelve patient records were reviewed April 21-22, 2010. Four patient records were reviewed for psychotherapy hours during the first two years of treatment. Three months were specifically reviewed, January, February and March 2010. Patient records # 2, 4 and 5 did not receive an average of at least 2.5 hours of psychotherapy.
Patient # 2 averaged 1.75 hours per month; patient # 4 averaged .25 hours per month and patient # 5 averaged 1.5 hours per month.
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Plan of Correction
The state regulations regarding psychotherapy services were reviewed at the general staff meeting on May 4, 2010, and the minutes were distributed to any staff who were not present.
The Clinical Director will review the regulations again in weekly group and individual supervision with clinicians.
The Clinical Director will also monitor documentation of counseling compliance with all clinical staff using the available program software. During the second week of the month, the Clinical Director will work with each clinician to identify any patients who are in danger of not meeting the monthly counseling requirements, and develop a plan to assist those patients in meeting the required hours as per their treatment plans.
Patients who are in danger of not meeting the monthly counseling requirement will be scheduled for additional counseling appointments, including individual and group session. Recalcitrant patients will be put on a counseling contract which will be reviewed with the patient weekly. Each patient will be scheduled for individual and group counseling in accordance with state regulations, using newly acquired scheduling software. Patients will also receive a written notice of their counseling appointments, which they will be required to sign to verify that they received the notice. For particularly problematic patients, individual counselors will be contacted by phone to remind them of their counseling appointments one day in advance. |
715.23(d) 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.
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Observations
Based on a review of patient records, the facility failed to document realistic short and long term goals in six of six patient records.
The findings include:
Twelve patient records were reviewed April 21-22, 2010. Six patient records were reviewed for documentation of short and long term goal statements on their respective treatment plans. Patient records # 2, 3, 4, 5, 9 and 10 contained short term goals that did not represent the stated long term goals. The long term goals were established to address one area of need while the short term goals addressed another area of need.
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Plan of Correction
The Clinical Director will utilize weekly individual and group supervision to critique long term and short term goals on treatment plans. Weekly group supervision will utilize the group format as a learning tool for all clinicians, and twice each month a treatment plan will be presented and critiqued by the group.
The Clinical Director will schedule an in-service training for counseling staff within the next six months that will address the relationship between long term and short term goals on the treatment plans. The Clinical Director and counseling staff will attempt to identify outside training opportunities to address treatment planning, and individual counselors will be sent whenever possible. These individual counselors will bring to the rest of the counseling staff any training materials they obtain at outside training, and share these with the other counselors.
The Clinical Director will review all treatment plans and identify any ongoing issues regarding long and short term goals, and those treatment plans that do not meet the standard will be rewritten prior to being signed by the Clinical Director. |
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 five patient records.
The findings include:
Twelve patient records were reviewed April 21-22, 2010. Five patient records were reviewed for treatment plan documentation compliance.
Patient records # 2, 9 and 10 contained behavioral steps for the patients to complete that were not relevant to the stated goals.
Patient record # 4 did not include behavioral steps for the patient to reach the stated treatment goals, but rather contained more objectives to meet.
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Plan of Correction
The Clinical Director will utilize weekly individual and group supervision to critique short term goals and behavioral tasks on treatment plans. Weekly group supervision will utilize the group format as a learning tool for all clinicians, and twice each month a treatment plan will be presented and critiqued by the group. Both satisfactory and unsatisfactory examples will be presented.
The Clinical Director will schedule an in-service training for counseling staff within the next six months that will address the relationship between short term and behavioral tasks on the treatment plans. The Clinical Director and counseling staff will attempt to identify outside training opportunities to address treatment planning, and individual counselors will be sent whenever possible. These individual counselors will bring to the rest of the counseling staff any training materials they obtain at outside training, and share these with the other counselors.
The Clinical Director will review all treatment plans and identify any ongoing issues regarding the relationship between short term goals and behavioral tasks, and those treatment plans that do not meet the standard will be rewritten prior to being signed by the Clinical Director. |