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 January 4-6, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Foundations Medical Services 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 February 10, 2011.
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Plan of Correction
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715.6(b)(1-9) LICENSURE Physician Staffing
(b) A narcotic treatment program may employ narcotic treatment physicians to assist the medical director. A narcotic treatment physician 's responsibilities include:
(1) Performing a medical history and physical exam.
(2) Determining diagnosis and determining narcotic dependence.
(3) Reviewing treatment plans.
(4) Determining dosage and all changes in doses.
(5) Ordering take-home privileges.
(6) Discussing cases with the treatment team.
(7) Issuing verbal orders pertaining to patient care.
(8) Assessing coexisting medical and psychiatric disorders.
(9) Treating or making appropriate referrals for treatment of these disorders.
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Observations
Based on the review of the personnel records and interviews with the director of the narcotic treatment programs and the facility director, the program failed to document that the narcotic treatment physicians responsibilities included determining diagnosis and determining narcotic dependence, reviewing treatment plans, determining dosage and all changes in doses, ordering take-home privileges, discussing cases with the treatment team., issuing verbal orders pertaining to patient care, assessing coexisting medical and psychiatric disorders and treating or making appropriate referrals for treatment of these disorders in two of three narcotic treatment physician personnel records.
The findings include:
Three personnel records were reviewed on January 5, 2011. Three personnel records were reviewed as narcotic treatment physician records. The facility did not document that the narcotic treatment physician responsibilities included determining diagnosis and determining narcotic dependence, reviewing treatment plans, determining dosage and all changes in doses, ordering take-home privileges, discussing cases with the treatment team, issuing verbal orders pertaining to patient care, assessing coexisting medical and psychiatric disorders and treating or making appropriate referrals for treatment of these disorders in personnel records # 1 and 2.
Interviews with the director of the narcotic treatment programs and the facility director occurred on January 5 and 6, 2011. The director of the narcotic treatment programs confirmed that the language documented in the physicians' contracts did not specifically list the language noted above.
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Plan of Correction
The CEO created an addendum to the physician contract which specifically included all required responsibilities.
The addendums were presented to and signed by the contracted physicians and CEO.
Contracts will be maintained by the CEO in conjunction with the Human Resources department.
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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
Based on a review of active patient case lists, the program monitoring questionnaire, and interviews with the director of the narcotic treatment programs and the facility director, the facility failed to maintain one FTE (full time equivalency) counselor for every 35 active patients, as required.
The findings include:
On January 4, 2011, the narcotic treatment program monitoring questionnaire and active patient case lists were reviewed. Per regulation, the counseling caseload for one FTE counselor in an outpatient narcotic treatment program may not exceed 35 active patients. The current census of the facility is 194 patients. Three counselors and one counselor assistant have a FTE of 38:1. One counselor has a FTE of 37:1. The facility failed to maintain one FTE counselor for every thirty-five active patients.
On January 4 and 6, 2011, the director of the narcotic treatment programs and the facility director were interviewed. They confirmed that the facility has five counselors who are over the 35:1 FTE. The facility director stated that she was unaware that an exception was needed for calculating a reduced caseload on the counselor caseloads.
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Plan of Correction
On January 12, 2011 the Director of Narcotic Treatment Programs submitted to the Department a caseload exception requesting a variance for the patient to counselor ratio.
Additional information has since been requested by the Department in consideration for final approval.
Requested information has been gathered and will be submitted upon receiving Board approval
New counselor was hired on January 31, 2011 and patients reassigned, thus reducing counselor caseloads to 1:35. Compliance to be monitored through counselor info grid. Grid will be submitted weekly to PD to check for accuracy. |
715.9(e) LICENSURE Intake
(e) A narcotic treatment program shall secure a personal history from the patient within the first week of admission. The personal history shall be made a part of the patient record.
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Observations
Based on the review of patient records and an interview with the director of the narcotic treatment programs and the facility director, the facility failed to document that a personal history from the patient was completed within the first week of admission in six of eight patient records.
The finding include:
Twenty two patient records were reviewed on January 4-6, 2011. Eight patient records reviewed required a personal history from the patient within the first week of admission. The facility did not document that the personal history was completed within the first week of admission in patient records # 2, 3, 12, 13, 14 and 15.
Patient # 2 was admitted on October 9, 2010. The personal history documented was not dated and therefore it could not be determined that the personal history had been completed
within the first week of admission.
Patient # 3 was admitted on July 24, 2010. The personal history documented was dated August 9, 2010. The personal history had not been completed within the first week of admission.
Patient # 12 was admitted on October 18, 2010. The personal history documented was not dated and therefore it could not be determined that the personal history had been completed within the first week of admission.
Patient # 13 was admitted on November 4, 2010. The personal history documented was not dated and therefore it could not be determined that the personal history had been completed within the first week of admission.
Patient # 14 was admitted on November 24, 2010. The personal history documented was not dated and therefore it could not be determined that the personal history had been completed within the first week of admission.
Patient # 15 was admitted on October 4, 2010. The personal history documented was not dated and therefore it could not be determined that the personal history had been completed
within the first week of admission.
An interview occurred with the director of the narcotic treatment programs and the facility director on January 6, 2011. The facility director stated that the new computer system did not have a tab for a date. She had found this and has taken measures to correct it.
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Plan of Correction
Revisions to the Electronic Health Record System have been requested. Requested changes are expected to be completed by 2/11/11. Changes will include the ability to date the personal history form on the EHRS to ensure compliance with regulation.
The Program Director will monitor compliance via random monthly chart audits.
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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 the review of patient records and interviews with the director of narcotic treatment program services and the facility director, the facility failed to ensure that the narcotic treatment physician determined the proper dosage level in one of eight patient records.
The findings include:
Twenty two patient records were reviewed on January 4-6, 2011. Eight patient records were reviewed for the physician's documentation in determining the initial dose. One out of eight patient records, specifically # 2 had a standing order documented for their initial dose.
Patient # 2 was admitted on October 9, 2010. Documented in patient record # 2 was an order by the physician that included a standing order to dose at 30 mg on October 9, 2010 and then 35 mg on 10/10/10, then 40 mg daily thereafter. There was no documentation that the narcotic treatment physician continued to assess the patient to determine if an increase in the patient's dose was needed.
An interview on January 5, 2011 with the facility director confirmed that the doctor had written a standing order for patient # 2.
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Plan of Correction
On October 11, 2010 a meeting was held with all of the physician staff to discuss writing orders.
The program physicians will determine the appropriate dosage level for the induction of a new client.
The client will remain at this dose until completing a dose assessment form and requesting an increase.
Upon receiving request, the program physician, through assessment, will adjust dosage according to determined need.
Compliance will be monitored by random monthly medical chart audits conducted by the program director and nursing staff.
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715.16(b)(1-8) LICENSURE Take-home privileges
(b) The narcotic treatment physician shall consider the following in determining whether, in exercising reasonable clinical judgment, a patient is responsible in handling narcotic drugs:
(1) Absence of recent abuse of drugs (narcotic or non-narcotic), including alcohol.
(2) Regular narcotic treatment program attendance.
(3) Absence of serious behavioral problems at the narcotic treatment program.
(4) Absence of known recent criminal activity.
(5) Stability of the patient 's home environment and social relationships.
(6) Length of time in comprehensive maintenance treatment.
(7) Assurance that take-home medication can be safely stored within the patient 's home.
(8) Whether the rehabilitative benefit to the patient derived from decreasing the frequency of attendance outweighs the potential risks of drug diversion.
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Observations
Based on a review of patient records and interviews with the director of the narcotic treatment programs and the facility director, the facility failed to document that the narcotic treatment physician considered the criteria for take-home privileges in one of three patient records.
The findings include:
Twenty two patient records were reviewed on January 4-6, 2011. Three patient records were reviewed for compliance with the regulations regarding take-home medications. 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 did not document that the narcotic treatment physician considered the criteria for take-home privileges in patient record # 13.
Patient # 13 was admitted into treatment on November 4, 2010. Patient # 13 transferred into treatment from another narcotic treatment program and was immediately granted take-home privileges per verbal order. There was no documentation that the criteria had been considered by the narcotic treatment physician prior to granting the take-home privileges in patient record # 13.
The director of the narcotic treatment programs and the facility director were interviewed on January 5, 2011 and confirmed that there was no documentation that the criteria had been considered prior to granting take-home privileges.
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Plan of Correction
The Program Director met with the physicians to discuss the importance of reviewing prior medical records and documentation when determining take home privilege status. The Physician will then clearly document in the record that the client meets the 8 point criteria for take homes on admission and any time thereafter.
The Program Director will complete random monthly chart audits and the nursing staff will review documentation daily to ensure compliance.
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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 the review of patient records and an interview with the facility director, the facility failed to document that the narcotic treatment program provided each patient an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment in five of six patient records.
The findings include:
Twenty patient records were reviewed on January 4-6, 2011. Six patient records were reviewed for compliance with an average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment. The facility failed to document an average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment in five patient records, # 2, 4, 6, 12 and 14.
Patient # 2 was admitted on October 9, 2010. The patient had 0 hours of psychotherapy documented in October 2010, 1.75 hours of psychotherapy documented in November 2010 and 2.50 hours of psychotherapy documented in December 2010 for an average of 1.42 hours of psychotherapy per month.
Patient # 4 was admitted on July 16, 2010. The patient had 1.5 hours of psychotherapy documented in October 2010, 1.25 hours of psychotherapy documented in November 2010 and 3 hours of psychotherapy documented in December 2010 for an average of 1.97 hours of psychotherapy per month.
Patient # 6 was admitted on October 18, 2010. The patient had 0 hours of psychotherapy documented in October 2010, 2.50 hours of psychotherapy documented in November 2010 and 0 hours of psychotherapy documented in December 2010 for an average of .833 hours of psychotherapy per month.
Patient # 12 was admitted on October 18, 2010. The patient had 0 hours of psychotherapy documented in October 2010, 2.75 hours of psychotherapy documented in November 2010 and 1.25 hours of psychotherapy documented in December 2010 for an average of 1.33 hours of psychotherapy per month
Patient # 14 was admitted on November 24, 2010. The patient had 0 hours of psychotherapy documented in November 2010 and 1.25 hours of psychotherapy documented in December 2010 for an average of .625 hours of psychotherapy per month.
The facility director was interviewed on January 5, 2011 and confirmed the above counseling hours.
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Plan of Correction
Counselors will put absolute stops on patients on the day of their scheduled appointments along with reminders the week prior to their appointment.
Counselors will discuss missed appointments with patients and incorporate missed appointments into their treatment plans.
Counselors will provide weekly reports to the program director via a client hours tracking log for ongoing monitoring.
The program director will monitor compliance through random monthly chart audits and clinical supervision.
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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 and an interview with the facility director, the facility failed document that the facility transferred patient files which included admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and contained the written consent of the patient in one of three patient records.
The findings include:
Twenty two patient records were reviewed on January 4-6, 2011. Three patient records were reviewed for documentation that the transferring narcotic treatment program transferred patient files which included the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and contained the written consent of the patient. There was no documentation that the facility transferred the documentation in patient record # 11.
Patient # 11 was admitted on September 9, 2009 and transferred to another narcotic treatment program on September 10, 2010. There was no documentation that the transferring narcotic treatment program transferred the patient files which included the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and contained the written consent of the patient
An interview with the facility director on January 6, 2011 confirmed that there was no documentation provided in patient record #5 that the program had transferred the required documentation.
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Plan of Correction
The Program Director conducted a training for all counselors regarding patient transfers to another treatment facility on January 17th.
Monitoring for ongoing compliance will be completed by the Program Director via random monthly chart audits and clinical supervision.
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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 patient records and staff interviews, the facility failed to 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 in one of three patient records.
The findings include:
Twenty two patient records were reviewed on January 4-6, 2011. Three patients were transferred into treatment from a narcotic treatment program. Per regulation, 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. The facility failed to 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 in record # 5.
Patient # 5 was transferred from a narcotic treatment program and admitted into treatment on January 5, 2011. There was no documentation that the facility notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient.
The facility director was interviewed on January 6, 2011. The facility director reviewed patient record #5 and confirmed there was no documentation that the transferring narcotic treatment program had been notified of the admission of the patient and the date of the initial dose given to the patient.
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Plan of Correction
The Program Director conducted a training for all counselors regarding patient transfers from another treatment facility on January 17th.
Monitoring for ongoing compliance will be completed by the Program Director via random monthly chart audits and clinical supervision.
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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 the review of patient records and an interview with the facility director, the facility failed to document that a discharge summary was completed per policy in five of eight patient records.
The findings include:
Twenty two patient records were reviewed on January 4-6, 2011. Eight patient records were reviewed for documentation that the discharge summary had been completed per program policy. Per program policy, discharge summaries are to be completed within 7 days. The facility did not document that the discharge summaries were completed per policy in patient records # 18, 19, 20, 21 and 22.
Patient # 18 was admitted on December 7, 2009 and discharged on August 24, 2010. The discharge summary was to be completed by August 31, 2010. The discharge summary documented did not contain a date of completion, therefore it could not be determined that the discharge summary had been completed per policy.
Patient # 19 was admitted on December 7, 2009 and discharged on July 31, 2010. The discharge summary was to be completed by August 7, 2010. The discharge summary documented did not contain a date of completion, therefore it could not be determined that the discharge summary had been completed per policy.
Patient # 20 was admitted on June 14, 2010 and discharged on September 20, 2010. The discharge summary was to be completed by September 27, 2010. The discharge summary documented did not contain a date of completion, therefore it could not be determined that the discharge summary had been completed per policy.
Patient # 21 was admitted on May 17, 2010 and discharged on October 29, 2010. The discharge summary was to be completed by November 5, 2010. The discharge summary documented did not contain a date of completion, therefore it could not be determined that the discharge summary had been completed per policy.
Patient # 22 was admitted on May 14, 2010 and discharged on October 18, 2010. The discharge summary was to be completed by October 25, 2010. The discharge summary documented did not contain a date of completion, therefore it could not be determined that the discharge summary had been completed per policy.
An interview with the facility director on January 6, 2010 confirmed the discharge summaries were not dated and the completion date could not be determined. The facility director stated that the new computer system did not have a tab for a date. She had found this and has taken measures to correct it.
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Plan of Correction
Revisions to the Electronic Health Record System have been requested. Requested changes are expected to be completed by 2/11/11. Changes will include the ability to date the discharge form on the EHRS to ensure compliance with regulation. Dates will be manually added by counselors until EHRS is updated.
The Program Director will monitor compliance via random monthly chart audits.
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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 the review of patient records and an interview with the facility director, the facility failed to document follow-up information per agency policy in three of eight patient records.
The findings include:
Twenty two patient records were reviewed on January 4-6, 2011. Eight patient records were required to document follow-up. Per program policy, follow up is to be completed in 30 days. The facility did not document a follow-up attempt per program policy in patient records # 11, 18 and 19.
Patient # 11 was admitted on September 9, 2009 and discharged on September 28, 2010. Follow-up was due on October 28, 2010. There was no documentation that a follow-up had been attempted.
Patient # 18 was admitted on December 7, 2009 and discharged on August 24, 2010. Follow-up was due on September 24, 2010. There was no documentation that a follow-up had been attempted.
Patient # 19 was admitted on December 7, 2009 and discharged on July 31, 2010. Follow-up was due on August 31, 2010. There was no documentation that a follow-up had been attempted.
An interview with the facility director on January 6, 2010 confirmed there was no documentation of follow-ups in the patient records.
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Plan of Correction
The Program Director conducted a training for all counselors regarding follow-up information being completed within 7 days of discharge on January 17th.
Monitoring for ongoing compliance will be completed by the Program Director via random monthly chart audits and clinical supervision.
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