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 19, 2010 through October 21, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Coatesville Treatment 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 November 19, 2010.
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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
Based on the review of administrative documentation and an interview with the Regional Director, the facility failed to provide at least one hour of physician time a week, on site, for every ten patients.
The findings include:
Physician time sheets and and census reports for the months of June, July, August and September were reviewed on October 19, 2010. There were insufficient onsite physician hours during July, August, and September. The facility has had an average of 443 patients during these three month, requiring a minimum of 44.3 physician hours per week. The facility failed to meet the required physician hours during the following weeks:
During the week of July 4 -10, 2010, there were 33.5 physician hours documented.
During the week of July 11-17, there were 38.5 physician hours documented.
During the week of August 1-7, 2010 there were 24 physician hours documented.
During the week of September 19 - 25, 2010, there were 41.25 physician hours documented.
An interview with the Regional Director confirmed that these were the only documented physician hours for those weeks.
This is a repeat citation from the monitoring visit conducted October 6-8, 2009.
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Plan of Correction
In order to have the required amount of documented physician hours consistently align with the patient census, the Clinic Director has contracted with a staffing agency to fill in for the narcotic treatment physician and/or physician assistant when they are scheduled for vacation time and offsite trainings. The narcotic treatment physician and physician assistant will contact the Clinic Director by 5:30a on the day they will be absent due to illness in order for the staffing agency to be contacted to send an available physician to cover the physician hours. The Clinic Director will be responsible for ensuring that coverage is scheduled for the physician and/or physician assistant during their paid time off. To ensure that there are enough physician hours to cover the census, the Clinic Director will track the time reporting by the end each month and compare it with the census report to ensure that the hours properly align. The physician and physician will be responsible for submitting their time off request at least three weeks in advance. These changes will begin 12/1/2010. |
715.9(a)(4) 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:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of 32 patient records on October 19 through 21, 2010, the narcotic treatment program failed to provide documentation that the narcotic treatment physician made a face-to face determination and documented in the patient's record the basis for the determination of an individual's physiological dependence upon a narcotic drug in records # 1, 14, and 18.
Findings:
In patient records #1, 14, and 18, there was no documentation verifying that the narcotic treatment physician made a face-to-face determination of the patient's physiological dependence upon a narcotic drug. This documentation was not presented during the monitoring.
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Plan of Correction
We are restructuring our current History and Physical documentation to clearly illustrate that the narcotic physician has had face-to-face with all patients admitted into the treatment program. The DON will review the chart after the patient meets with the physician to ensure that all History and Physical documentation has been thoroughly completed and all required signatures have been obtained. The Clinic Director and Clinical Supervisors will ensure that all previous versions of the History and Physical are discarded of appropriately. There will be a training with the medical and clinical staff on 12/8/2010 to review the changes and to ensure that all are aware of the procedures and documentation involved with the History and Physical. There will be a sign-in sheet kept on file of this training. These changes will begin on 12/9/2010, after the completion of the staff training on 12/8/2010. |
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 the review of patient records, the facility failed to ensure at least monthly random urine drug screens for 6 of 14 patient records.
The findings include:
Thirty-two patient records were reviewed October 19-21, 2010. Fourteen patient records were reviewed for monthly urine drug screen results.
Patient record # 2 was missing a urine drug screens for June and September 2010.
Patient record # 3 was missing a urine drug screen for September 2010.
Patient record # 5 was missing a urine drug screens for May, July and September 2010.
Patient record # 21 was missing a urine drug screen for December 2009 and May 2010.
Patient record # 22 was missing a urine drug screen for August 2010.
This is a repeat citation from the monitoring visit conducted October 6-8, 2009.
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Plan of Correction
The nursing staff will conduct a mid-month audit through the use of the new dispensing system, Tower, every month to ensure that each patient has been scheduled for and given a monthly drug-screen urinalysis. Urine drug screens will now be given during the weekends as needed to avoid any patient from being missed. The counseling staff will also conduct a mid-month audit through the use of the new dispensing system to ensure that their patients have been scheduled for and given a monthly drug-screen urinalysis. The DON will maintain overall responsibility to ensure that the urine drug screens are being completed for each patient monthly. These changes will begin on 12/1/2010. |
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 and a staff interview, the narcotic treatment program failed to provide documentation of the consultation between the narcotic treatment physician determining the initial dose and the narcotic treatment physician performing the physical examination in 1 of 2 records.
Findings
In patient record #14, the narcotic treatment physician determining the initial dose failed to document the consultation with the certified physician assistant (PA-C) or other narcotic treatment physician completing the physical examination.
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Plan of Correction
The narcotic treatment physician will clearly document all consultation between himself/herself and the certified physician assistant regarding initial dose orders. Prior to the documentation being filed, the Director of Nursing will verify that all required documentation has been completed by the narcotic treatment physician and physician assistant. There will be a meeting with the Director of Nursing, physician, physician assistant, and Clinic Director to view the above procedures on 11/30/2010 for the changes to take effect on 12/1/2010. |
715.16(c)(3)(i-viii) 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:
(3) A narcotic treatment program may permit a patient to reduce attendance at the narcotic treatment program for observation to one time weekly and receive no more than a 6-day take-home supply of medication when in the reasonable clinical judgment of the narcotic treatment physician, which is documented in the patient record:
(i) A patient demonstrates satisfactory adherence to narcotic treatment program rules for at least 3 years.
(ii) A patient demonstrates substantial progress in rehabilitation.
(iii) A patient demonstrates responsibility in handling narcotic drugs.
(iv) A patient demonstrates that rehabilitation progress would improve by decreasing the frequency of attendance for observation.
(v) A patient demonstrates no major behavioral problems.
(vi) A patient is employed, is actively seeking employment, attends school, is a homemaker or is considered unemployable for mental or physical reasons.
(vii) A patient is not known to have abused alcohol or other drugs within the previous year.
(viii) A patient is not known to have engaged in any criminal activity within the previous year.
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Observations
Based on a review of patient records and staff interviews, the facility failed to consider the criteria for take-home privileges in one of two patient records.
The findings include:
Thirty-two patient records were reviewed on October 19-21, 2010. Eight patient records were reviewed for compliance with the regulations regarding take-home medications. Two of those eight were reviewed for a six-day take home supply. Per regulation, the narcotic treatment physician shall consider the following in exercising reasonable clinical judgment, a patient is responsible in handling narcotic drugs: absence of recent abuse of drugs (narcotic or non-narcotic), including alcohol, regular narcotic treatment program attendance, absence of serious behavioral problems at the narcotic treatment program, absence of known recent criminal activity, stability of the patient 's home environment and social relationships, length of time in comprehensive maintenance treatment. assurance that take-home medication can be safely stored within the patient 's home, and whether the rehabilitative benefit to the patient derived from decreasing the frequency of attendance outweighs the potential risks of drug diversion. The facility failed to consider the criteria for take-home privileges in patient records # 12.
Patient # 12 was admitted into treatment on September 26, 2006. A review of documentation revealed that patient # 12 was not meeting the eight point criteria to have take-home privileges as he had failed to meet the required counseling hours for January, February, March, and August of 2010. Additionally, documentation in the patient record revealed the patient is currently unemployed and self reported marital problems.
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Plan of Correction
The Clinical Supervisors will conduct training on the guidelines for receiving take home privileges to include the eight point criteria and for rescinding and reinstating take home privileges by 12/31/10. The guidelines have been written in the form of policy and procedures and will be distributed to staff by the Clinical Supervisors. The policy and procedures pertaining to rescinding and reinstating take homes covers the following: lapse, relapse, attendance requirements, and call backs. Counselors will be responsible for completing a bi-monthly case consultation for all patients receiving take home privileges to clearly demonstrate the patient's continuum of meeting the criteria to maintain their current take home level. The Clinical Supervisors will be responsible for ensuring that counselors are completing the case consultations within the appropriate timeframes. To ensure that all the above procedures are followed, both Clinical Supervisors will conduct a total of 15 random chart audits per month and submit correction notifications to the counselors. These changes will begin on 12/31/2010. |
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 that the physician dated the signature after submitting a verbal order in five of five patient records reviewed.
The findings include:
Thirty-two patient records were reviewed October 19-21, 2010. Five records contained documentation of a physician's verbal orders. While the physician did sign these verbal orders, the signature was not dated in patient records # 6, 7, 15, 16, and 20. Therefore, it could not be determined whether the verbal order was signed within 24 hours as required by regulation.
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Plan of Correction
After a meeting with the physician, physician assistant, and Clinic Director on 11/3/2010, the narcotic treatment physician has begun signing and dating all verbal orders. In the new dispensing system, medication orders are printed with the two separate lines for signature and dates for the nursing staff member who took the verbal order and for the narcotic treatment physician. The new system that was installed on 9/21/10 will help to ensure that all verbal orders have been signed and dated by the nursing staff and physician. The Director of Nursing has met with the nursing staff to review the above procedure and has communicated that the nursing staff will be responsible for ensuring that all orders have been signed and dated by the required persons. The Director of Nursing will be conducting 10 random chart audits each month to ensure the above procedures are followed. These changes began on 11/4/2010. |
715.17(c)(1)(i-vi)) 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:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on the review of patient records, the narcotic treatment program failed to ensure that the narcotic treatment physician determined the proper dose for each patient.
The findings include:
Thirty-two patient records were reviewed on October 19-21, 2010. Three patient records were reviewed for the physician's documentation of patient dose determination. Three out of three records, specifically, 2, 3, and 8 had standing orders for the initial dose and induction. These orders allowed someone other than the doctor to determine a dose change.
Patient # 2 received an initial dose of 20 mg. Documented in patient record # 2 was an order by the physician that included, "standard induction- dose range 20-80. May increase 10 mg daily until 60 mg. Hold at 60 mg for four days. May increase 5 mg every four days afterwards until 80 mg. Not more than 10 mg daily increase. Please dose according to symptoms. Hold for sedation." There was no documentation that the narcotic treatment physician continued to assess the patient to determine if a dose increase was needed.
Patient # 3 was a transfer to the facility and received an initial dose of 60 mg. Documented in patient record # 3 was an order by the physician that included, "Transferred from another (narcotic treatment program). Received her last dose of methadone 50 mg on 4/12/2010, today methadone 60 mg. Patient may increase 10 mg/day up to 150 mg.; hold dose at 150 mg." There was no documentation that the narcotic treatment physician continued to assess the patient to determine if a dose increase was needed.
Patient # 8 received an initial dose of 30 mg. Documented in patient record # 8 was an order by the physician that included, "V.O. (verbal order) standard induction. Today 30 mg. Range 20 mg to 80 mg. Base dose on signs and symptoms of withdrawal. Hold for sedation. No increase more than 10 mg/day once at 60 mg. No increase more than every four days/RD." There was no documentation that the narcotic treatment physician continued to assess the patient to determine if a dose increase was needed.
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Plan of Correction
Beginning 12/1/10, all patients admitted into the program will be individually assessed by the narcotic treatment physician to determine the appropriate dose level based on their reported symptoms. All medication orders will clearly document patient symptoms to illustrate the reasoning for the change in medication level and will be signed by the physician. The nursing staff will be responsible for ensuring that all orders clearly document that the patient has been accessed by the physician and clearly documents the patients reported symptoms. These changes will begin on 12/1/2010. |
715.17(c)(7) 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:
(7) Drug reactions and medication errors. A narcotic treatment program shall report any adverse drug reaction or medication error to a narcotic treatment physician immediately and initiate corrective action. The narcotic treatment program shall record the reaction or error in the drug administration record and the clinical chart, and shall inform each person who is authorized to administer medication or supervise self-medication of the reaction or error.
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Observations
Based on a review of patient incident reports on October 21, 2010, the narcotic treatment program failed to document that the Narcotic Treatment Physician was notified of a medication error.
Findings
In patient record # 32 the incident report documented that the patient received the wrong dose on 6/29/2010. The report stated that the patient received 30 mg more than was ordered. The report stated, "tagged to meet with patient the next day to review any effects." There was no documentation that the physician was notified of the medication error.
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Plan of Correction
All medication errors will be reported to the narcotic treatment physician and documented by the nursing staff through an internal Incident Report that will be maintained in a binder located in the Clinic Director's office. The incident report will clearly document that the physician was notified of the medication error. The DON will be responsible for ensuring that all medication errors are reported to the physician and clearly documented. The DON will maintain a tracking system to ensure that the physician has been made aware of all medication errors. The DON will meet with the nursing staff by 11/30/2010 to review the above procedures as the changes will begin 12/1/2010. |
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 7 of 11 records.
The findings include:
Thirty-two patient records were reviewed October 19-21, 2010. Eleven patient records were reviewed for psychotherapy hours during the first year of treatment. The facility failed to document and provide 2.5 hours of required psychotherapy per month in patient records
# 2, 4, 5, 6, 7, 22, and 23.
Patient # 2 was admitted into treatment on May 10, 2010. The patient attended 1.5 hours of psychotherapy in July, 2 hours of psychotherapy in August and 2.5 hours of psychotherapy in September. Patient # 2 attended an average of 2 hours of psychotherapy per month.
Patient # 4 was admitted into treatment on June 7, 2010. The patient attended 1 hour of psychotherapy in July, 2.5 hours of psychotherapy in August and 2.5 hours of psychotherapy in September. Patient # 4 attended an average of 2 hours of psychotherapy per month.
Patient # 5 was admitted into treatment on March 25, 2009. The patient attended 0 hours of psychotherapy in July, 0 hours of psychotherapy in August and 1 hour of psychotherapy in September. Patient # 5 attended an average of .33 hours of psychotherapy per month.
Patient # 6 was admitted into treatment on March 18, 2009. The patient attended .5 hours of psychotherapy in July, 2.5 hours of psychotherapy in August and 0 hours of psychotherapy in September. Patient # 6 attended an average of 1 hour of psychotherapy per month.
Patient # 7 was admitted into treatment on February 19, 2010. The patient attended 2.5 hours of psychotherapy in July, 2.5 hours of psychotherapy in August and .5 hours of psychotherapy in September. Patient # 7 attended an average of 1.83 hours of psychotherapy per month.
Patient # 22 was admitted into treatment on June 25, 2010. The patient attended 1 hour of psychotherapy in July, 1.5 hours of psychotherapy in August and 0 hours of psychotherapy in September. Patient # 22 attended an average of .83 hours of psychotherapy per month.
Patient # 23 was admitted into treatment on July 8, 2010. The patient attended 0 hours of psychotherapy in July, 2 hours of psychotherapy in August and 0 hours of psychotherapy in September. Patient # 23 attended an average of .66 hours of psychotherapy per month.
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Plan of Correction
With the new dispensing system, the counseling staff will have the ability to alert patients daily of upcoming appointment. As patients must check in at the front desk with the front desk office manager prior to dosing, the alert will display on their information page. Counselors will be responsible for flagging their patients in the system. Beginning 12/15/10, counselors will schedule all counseling sessions through the dispensing system. If a patient misses their session, the counselor will be immediately place an alert on the dispensing system to meet with their counselor prior to dosing on the next business day. Patients that consistently miss their counseling appointments will be given a scheduled dosing time at 12:29p by the Clinical Supervisors and the counselor will add non-compliance with counseling requirement to the treatment plan and a behavioral contract will be created as needed. For patients that have consistently missed their counseling sessions, counselors will place an alert on the system noting that the patient has to attend their counseling sessions prior to dosing. Clinical Supervisors will utilize a monthly counseling tracking report to monitor patient participation in counseling and will address all issues of non-compliance with the patient and their counselor. Clinical Supervisors will also conduct a training by 12/14/2010 to go over these procedures with the counseling staff for the changes to take effect on 12/15/2010. |
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 have the transferring narcotic treatment program provide patient information to 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.
The findings include:
Thirty-two patient records were reviewed on October 19-21, 2010. Four patient records were reviewed for documentation from the transferring narcotic treatment program. The facility failed to obtain the required documentation in two out of four records reviewed, specifically records, # 13 and 21.
Patient record # 13 failed to document the admission date, medical and psychosocial summaries from the referring facility. The facility only received the urinalysis report, dosing records and history and physical.
Patient record # 21 had a consent that was restricted to 255.5, therefore not all the required documentation was received from the referring facility.
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Plan of Correction
There will be now one counselor and both Clinical Supervisors handling all transfers from referring facilities to ensure that all the require documentation is received. A transfer release will be faxed to the referring facility that specifically highlights all the required documentation. The counselor in charge of handling transfer will ensure that all documentation has been received from the referring facility prior to the patient being admitted into the program. The counselor will also fax over a letter confirming that the patient was admitted into treatment once the transfer has been completed. All transfer documentation from the referring facility will be kept in the patient chart up until a year and then relocated to an overflow chart that will be maintained in the chart room and be provided along with the active chart during state monitoring visits. The Clinical Supervisors will be responsible for reviewing the charts of transfer patients to ensure all required documentation pertaining to the transfer has been completed. These changes will begin 12/1/2010. |
715.20(4) 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.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of 32 patient records on October 19-21, 2010, the narcotic treatment program failed to document, in writing, that it notified the transferring narcotic treatment program of the admission of the patient and the initial dose given in one of two records, as required.
Findings
In patient record #1, there was no documentation in the record that the narcotic treatment program notified the transferring narcotic treatment program of the patient's admission and initial dose. This documentation was not presented during the on-site monitoring.
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Plan of Correction
The Clinical Supervisors will maintain a tracking sheet for all transfers that highlight the following: patient name, date of admission, referring facility, and confirmation of the acceptance into the program. If a patient has been transferred in from another facility, the Clinical Supervisors or transfer counselor will fax a letter notifying the other facility of the patient admission date and initial dose. If a patient is being referred out to another facility, the Clinical Supervisors or transfer counselor will fax over a letter requesting written verification of the patient's admission date and initial dose. All written confirmations will be filed in the patients chart along with being documented on the tracking sheet maintained by the Clinical Supervisors. Clinical Supervisors will provide training on transfers as well as appropriate release to utilize for transfers and other requests by 12/14/10 for the changes to begin on 12/15/2010. The Clinical Supervisor will be responsible for ensuring that all required documentation has been completed and maintained in the patient's chart by conducting a chart audit. The chart audits will be kept in the offices of the Clinical Supervisors. |
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 the review of patient records, the facility failed to restrict the reasons for involuntary termination to those reasons allowed by regulation in one of four patient records.
The findings include:
Thirty-two patient records were reviewed October 19-21, 2010. Two patient records were reviewed for involuntary, or therapeutic, discharge. One patient record contained documentation of the patient being discharged for reasons other than those listed by regulation.
Patient # 17 was discharged for refusing to provide a urine three times in a row on March 25, 2010, March 29, 2010, and March 31, 2010. The reason for termination from the program did not fall within the reasons allowed per regulation.
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Plan of Correction
The Clinical Supervisors will conduct a training with the medical staff and clinical staff by 12/14/10 that covers the state regulations pertaining to patient terminations so that all staff understand the appropriate means for discharge. These changes will begin on 12/15/2010. Each week there is a medical staff meeting to review patient cases including urine drug screens. Beginning 12/15/2010, all cases presented by the counselors including involuntary terminations will be reviewed by the Clinical Supervisors during the medical staff meetings to ensure that all requirements have been met in terms of involuntary terminations prior to the physician reviewing, approving, and signing off on the termination. |
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 patient records, the facility failed to complete all required laboratory tests as part of the admission process in nine of ten patient records reviewed.
The findings include:
Thirty-two patient records were reviewed October 19-21, 2010. Ten patient records were reviewed for completed laboratory tests as part of the admission process, specifically serological testing.
Patient records # 1, 2, 3, 4, 7, 8, 14, 18, and 22 did not have documentation that serological testing was completed as a part of the admission process.
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Plan of Correction
All patients admitted into the program will have their blood drawn by the nursing staff in order to have all required laboratory testing completed. The nursing staff will provide one another with assistance if one nurse encounters difficulty with obtaining a blood sample. If the nursing staff is absolutely unable to obtain a blood sample, the physician will provide a hard stick script and the incident will be clearly documented by the nursing staff and placed in the patient's chart. If a new admitted patient is dehydrated due to withdrawal, their blood will be drawn one to two weeks post admission and there will be an alert placed in the dispensing system to have the blood redrawn as well as a nursing note will be placed in the patients chart documenting the incident. The nursing staff will have monthly meetings to ensure that all medical protocols are being followed and are meeting state regulations. The DON will conduct a review through the patient dispensing system by the end of each week to ensure that patients' blood have been drawn at intake. If the blood has not been drawn, the DON will be responsible for ensuring that this has been completed. The DON will conduct a training with the nursing staff by 11/30/2010 to ensure that the staff understand the above procedures. These changes will begin on 12/1/2010. |
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 the review of patient records, the facility failed to document the attempt or completion of patient follow-up contact in 7 of 9 patient records reviewed.
The findings include:
Thirty-two patient records were reviewed October 19-21, 2010. Nine patient records were reviewed for follow-up documentation.
Patient records # 16, 17, 24, 25, 26, 27 and 28 did not have documentation of patient follow-up attempt or contact.
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Plan of Correction
All discharge follow-ups will be managed by the Clinical Supervisors. They will maintain a tracking sheet that will highlight that the follow-up has been completed and the information will be keep in binders located in their offices. The Clinical Supervisors will complete the follow-up within 7 days of discharge. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on review of administrative documentation provided during the inspection and staff interviews, the facility failed to submit documentation of unusual incidents to the Department as required.
The findings include:
Unusual incident documentation was reviewed on October 21, 2010. There was no documentation regarding incident reports sent to the Department of Health, such as fax confirmation sheets. An interview with the Regional Director confirmed that there was no method to determine whether or not incident reports were being filed with the Department of Health.
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Plan of Correction
All unusual incidents will be reported to the Department of Health within 24 hours of the incident by the Clinic Director. All unusual incidents will also be tracked in an internal incident reporting system and hard copies of the reports will be maintained in a binder located in the Clinic Director's office along with the report sent to the Department of Health.
All staff will notify the Health and Safety Officer and Clinic Director of all unusual incidents via email. The staff member or members that have witnessed the incident will submit an internal incident report to the Health and Safety Officer. The Clinic Director will ensure that all incident reports have been submitted to the Health and Safety Officer. The Health and Safety Officer will enter the report into the reporting system and provide the Clinic Director with a copy. The Health and Safety Officer will conduct training by 12/30/10 that all staff must attend to review the topic of Unusual Incident Reporting so that the above changes will begin on 12/31/2010.
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