INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use a narcotic agent, specifically methadone, in the treatment of narcotic addiction. This inspection was conducted on September 26, 27, and 28, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Foundations Medical Services, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on October 19, 2007. .
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Plan of Correction
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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
The facility failed to have physician documentation of current dependency and history of addiction for patients # 1 and 14. In both situations there is evidence that the physician met with the patients upon admission but did not document each patient's current dependency and history of addiction.
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Plan of Correction
715.9 a4
Time Frame ? immediately
Methodology Physician will document current dependency and history of addiction on current form for all admissions Compliance will be monitored by the chart monitor and director for all new intakes
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715.9(b)(2) LICENSURE Intake
(b) Exceptions to the requirements in subsection (a) are:
(2) Upon readmitting a patient who has been out of a narcotic treatment program for 6 months or less after a voluntary termination, the narcotic treatment program shall update the information in and review the patient 's file to show current opiate narcotic dependency, but need not conduct a physical examination and applicable laboratory tests. Privileges earned during the previous treatment may be reinstated at the discretion of the narcotic treatment physician.
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Observations
The facility failed to update the patient record to show current opiate dependency in two (record #19 and 20) patient records reviewed. The patient record showed patient #20 was readmitted on August 16, 2007 without completion of a drug screen while patient # 19 returned to treatment on 8/28/07 and did not submit to a drug screen until date of readmit. In both cases, the physician failed to document current dependency.
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Plan of Correction
715.9 (b) 2
Time Frame ? immediately
Methodology- Physician will document current opiate dependency on all readmits. Drug screens will be completed on all readmits. Compliance will be monitored by chart monitor and the director for all readmits
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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
The facility failed to complete a drug screen urinalysis for patient # 13 during the month of August, 2007.
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Plan of Correction
715.14a
Time frame- immediately
Methodology Random drug screens will be completed once a month on all patients. Compliance will be monitored by counselors who put the drug screens in the computer and by chart monitoring
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715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
The facility failed to have the physician perform a bi-annual dosing review for patient # 11. Specifically, there was no documentation to show evidence of any dose review.
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Plan of Correction
715.15 a
Time frame ? immediately
Methodology- Physician will perform a bi-annual dosing review for all patients to determine a therapeutic dose. Physician will document all reviews. A log will be kept for all reviews, Compliance will be monitored by the medical staff and the director
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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
The facility failed to document that only the physician may make dose determinations; documentation in patient # 12's chart indicated that patient's counselor had entered a specific amount for a dose change.
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Plan of Correction
715.15b
Time Frame-immediately
Methodology- only a physician will make dose determinations and enter a specific amount for a dose change. Physician will make all determinations of doses and document the rationale for the change. Compliance will be monitored by chart monitors and the nursing staff Compliance will be monitored by a new physician communication sheet.
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715.16(a)(2) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(2) The narcotic treatment physician shall make this determination after consultations with staff involved in the patient's care.
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Observations
The facility failed to document that the physician consulted with staff prior to determining take home medication status; specifically, patient records # 6, 8, 10, and 15 did not include documentation that the physician had consulted with the staff prior to the decision to change take home medication privileges.
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Plan of Correction
715.16 a2
Time frame ?immediately
Methodology- The physician will consult with the staff involved in the patient's care to
determine whether a patient needs take home medications. This will be monitored by the nursing staff , the director, and by chart monitoring.
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715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
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Observations
The facility physician failed to document the rationale of ordering take-home privileges for patients # 6, 8, 10, and 15.
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Plan of Correction
715.16 a3
Time Frame ? immediately
Methodology- . Physician will document the rationale for ordering take home privileges for patients. Compliance will be monitored by the nursing staff, director and chart monitoring.
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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
The facility failed to provide patients # 5, 7, 12, 13, and 15 with the required 2.5 hours of psychotherapy during the months of July, August, and September, 2007.
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Plan of Correction
715.19 1
Time frame ? immediately- by November 18,2007
Methodology. ? Patients will be provided with 2.5 hours of counseling per month. Compliance will be monitored by chart monitoring, and peer review.
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715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
The facility failed to document that patient #15 received the minimum required one hour of psychotherapy during the months of July and August, 2007.
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Plan of Correction
715.19
Time frame ? immediately ? by- November 18, 2007
Methodology- Patients will be provided with 1 hour of psychotherapy by their counselor every month. Compliance will be monitored by chart monitoring and peer review.
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715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
The facility failed to provide documentation that patient # 10 had met the minimally required half hour of individual psychotherapy every month, specifically August and September, 2007.
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Plan of Correction
715.19 3
Time frame- immediately-by November 18, 2007
Methodology- Patients will be provided with 1 hour of individual psychotherapy every 2 months by their counselors. Compliance will be monitored by chart monitoring and peer review
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715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
The facility physician failed to document patient # 1's vital signs when he conducted the initial physical exam.
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Plan of Correction
715.23b4
Time frame- immediately
Methodology- The physician will document all vital signs when he conducts an initial physical exam. Compliance will be monitored by chart monitoring and director
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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
The facility failed to provide documentation of vital signs for patient # 12 during the the annual
physical evaluation.
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Plan of Correction
715.23b5
Time frame ? immediately
Methodology- The physician will document all vital signs when he conducts an annual physical. Compliance will be monitored and documented in the annual physical log by the nursing staff/physician
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715.23(b)(11) LICENSURE Patient records
(b) Each patient file shall include the following information:
(11) Counselor notes regarding patient progress and status.
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Observations
The facility failed to document progress notes as required by facility policy and procedures. A progress note for patient #11 was three weeks late and patient # 12 had a progress note that was recorded two weeks late. Additionally, in patient # 12's indicated that a counseling session was held on September 14, 2007 and there was no progress note that addressed this session.
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Plan of Correction
715.23 b 11
Time frame- immediately
Methodology- All progress notes will be completed by counselors and documented for all sessions. Compliance will be through chart monitoring and peer review
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715.23(b)(13) LICENSURE Patient records
(b) Each patient file shall include the following information:
(13) Patient record of services.
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Observations
The facility failed to maintain a record of services that correlated with the progress notes recorded for patient # 14.
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Plan of Correction
715.23 b13
Time frame- immediately
Methodology- All records of service will correlate with the progress notes and be completed by counselors Compliance will be through chart monitoring and peer review
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715.23(b)(22) LICENSURE Patient records
(b) Each patient file shall include the following information:
(22) Aftercare plan, if applicable.
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Observations
The facility failed to follow its policy and procedures regarding aftercare plan content. Patient # 2's aftercare plan lacked information on the counseling appointment that had been arranged for the patient prior to discharge. Aftercare plans were generic, non-specific, and lacked measurable goals for patient to pursue after discharge.
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Plan of Correction
715.23 b22
Time frame- immediately
Methodology- After care plans will be completed by counselors and will document all appointments prior to discharge. After care plans will have measurable goals completed by counselors. Compliance will be monitored by the director in an aftercare log for all patients who have successfully completed treatment
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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
The facility failed to maintain consistency between policy and procedure and actual practice. Facility policy indicated contact would be attempted 90 days following discharge while contact is attempted in writing within one week of patient discharge.
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Plan of Correction
715.23 b24
Time frame- immediately
Methodology- Follow up information will be obtained following policy and procedure following treatment by the counselor. Compliance will be monitored by the director and by chart monitoring
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
The facility failed to document patient care and status changes for patients # 2, 5, 13, and 15. The documentation included one word answers and did not address changes specific to the past year, i.e. discharge and readmit, family and legal issues, etc.
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Plan of Correction
715.23c1-7
Time frame ? immediately
Methodology- All annual evaluations will address changes in employment, education, legal standing, substance abuse, financial management, physical and mental health, fulfillment of treatment objectives and family and community supports and will be completed by counselors. One word answers are not acceptable. Compliance will be monitored by program director
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715.29(5) LICENSURE Exceptions
A narcotic treatment program is permitted, at the time of application or any time thereafter, to request an exception from a specific regulation.
(5) If the exception relates to a specific patient, the narcotic treatment program shall maintain documentation of the exception in the patient 's record.
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Observations
The facility failed to comply with the conditions of the exception granted by the Division regarding six day take-home privileges. The facility failed to conduct quarterly call backs as required by the exception for patients # 10, 11, 15, and 17. Patients on six day status based on the exception must have quarterly call backs (an unscheduled return to the facility within 24 hours) that includes an inventory of patient's remaining take home supply and drug testing or methadone plasma levels. The primary counselor failed to document continued justification for the 6 day take home privilege.
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Plan of Correction
715.29 5
Time frame- Immediately
Methodology- Quarterly call backs will be conducted on all patients with 6 day take homes by counselors. A call back log has been developed for all patients who have 6 day take homes by director. Compliance will be monitored by the director
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