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 November 13-15, 2012 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.
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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, the facility failed to provide at least one hour of physician time a week, on site for, every ten patients for seven of the nineteen weeks reviewed.
The findings include:
Physician time sheets for the months of July, August, September, October and the beginning of November 2012 were reviewed on November 14, 2012. Seven weeks demonstrated insufficient onsite physician hours.
During the week ending July 7, 2012, the patient census was 215. The facility was required to provide at least 21.5 physician hours. There were 0 physician hours documented.
During the week ending August 11, 2012, the patient census was 209. The facility was required to provide at least 20.9 physician hours. There were 12.5 physician hours documented.
During the week ending September 1, 2012, the patient census was 208. The facility was required to provide at least 20.8 physician hours. There were 12.5 physician hours documented.
During the week ending September 29, 2012, the patient census was 205. The facility was required to provide at least 20.5 physician hours. There were 17.5 physician hours documented.
During the week ending October 6, 2012, the patient census was 206. The facility was required to provide at least 20.6 physician hours. There were 17.5 physician hours documented.
During the week ending October 13, 2012, the patient census was 206. The facility was required to provide at least 20.6 physician hours. There were 17 physician hours documented.
During the week ending November 3, 2012, the patient census was 207. The facility was required to provide at least 20.7 physician hours. There were 18 physician hours documented.
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Plan of Correction
The Program Director will review the Physician hours to determine the appropriate course of actions to be taken to ensure sufficient coverage is obtained based on staffing regulation 715.6(d).
The Program Director, Medical Director, and Director of PA Operations have reviewed policy 715.6(d). The Medical Director will submit a monthly doctor's hours schedule to the Program Director for review. The Program and Medical Director will ensure to pay close attention to holiday's and vacation time. Adjustments will be made to the schedule by the Medical Director in accordance to current census. A weekly census report will be run to ensure we are in compliance with the required doctor-patient time ratio.
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715.20(3) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document what materials were sent to the receiving narcotic treatment program in two of two patient records.
The findings include:
Twenty patient records were reviewed November 13-15, 2012. Two records required documentation of the materials sent to the receiving provider of the transfer. In patient records five and seventeen there was no documentation of the information that was required to be sent to the receiving narcotic treatment program.
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Plan of Correction
The Program/Clinical Director will review 715.20(3) during group supervision sessions on December 10, 2012, and document the same to ensure full compliance to this policy.
The review will include the verbatim reading of the policy and the insurance that all appropriate documentation is included on an updated checklist of documentation to be sent for transfer purposes.
All subsequent transfers, and more specifically the paperwork associated to these transfers, will be reviewed by the Clinical Director prior to forwarding documentation to ensure all forms are included in the communication as noted within the regulation.
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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 the review of patient records, the facility failed to document that it notified the referring facility of the admission and initial dosing of the patient in one of two patient records.
The findings include:
Twenty patient records were reviewed November 13-15, 2012. Two patient records were reviewed for documentation of notification to the referring facility of the admission and initial dosing of the referred patient.
Patient # 5 was referred by another narcotic treatment program and there was no documentation of the referral source's notification of the admission and initial dosing of the patient.
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Plan of Correction
The Program/Clinical Director will review 715.20(4) during group supervision sessions on December 10, 2012 and document the same to ensure full compliance to this policy.
This review will include the necessity to document all contacts to the transferring NTP to acknowledge receipt and/or admission of the patient on the first date of their scheduled dosing.
A scheduled review will be completed for any and all transferring patients by the Clinical Director and/or their designee, to ensure compliance to this regulation and contacts to referring agency will be completed by the Clinical Director and/or their designee.
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715.21(1)(i-iv) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
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Observations
Based on a review of patient handbook and the policy and procedure manual, the facility failed to restrict their policy and procedure on involuntary terminations to those areas specified in the regulations.
The findings include:
A review of the patient handbook on November 13, 2012 revealed that patients were informed they could be terminated for reasons other that those specified by regulations. According to the handbook documentation, patients could be terminated for reasons such as loitering, illicit drug use, funding/insurance issues and nonpayment for treatment services.
A review of the policy manual on November 13, 2012 revealed patients could be terminated for suspicious behaviors, falsifying urine drug screens, loitering, repeated non-compliance of safe parking laws, repeated failure to comply with the no visitor rule, failure to pay, and an immediate discharge without provision for detoxification when a physician "reasonably" determines continuous treatment presents serious risk.
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Plan of Correction
A review of the patient handbook and subsequent internal policies related to this matter will be reviewed and edited to reflect the language appropriate to 715.21(1)(i-iv). An initial review and edit to NTP Policies has been completed on December 3-4, 2012.
Once a final draft is disseminated and completed these Policies will be reviewed during the Monthly staff meeting in December and during routine Group Supervisory sessions to ensure compliance and appropriate actions taken with regard to involuntary terminations from MAT.
With regard to the Patient handbook, appropriate edits will be made and provided to all patients via additional dissemination of handbooks and postings being placed on the patient communication board within the lobby area of the facility.
Additionally, reviews will be provided during Orientation groups, individual sessions and other group dynamics; ongoing.
Areas noted within the handbook specific to discharges that are viewed to be in excess of the State Regulations will be handled clinically; using Clinical Compliance Agreements (CCA) and noted as Treatment plan updates. These will be presented to patients. The CCA's will be clear in detailing the specific behavior that is construed to be a violation of the clinic's program rules and will provide specific time frames for patient compliance. Progress to the same will be added to the Tx Plan and areas requiring continued clinical attention will be added to the Tx plans when updated. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on the review of patient records, the facility failed to complete the annual physical with a re-evaluation by the physician in four of four patient records reviewed.
The findings include:
Twenty patient records were reviewed November 13-15, 2012. Four patient records required an annual physical examination which included a reevaluation by the physician.
Patient # 2 was admitted September 16, 2010. The annual physical exam was completed on September 18, 2012 by the physician, but it did not include a re-evaluation by the physician as required.
Patient # 6 was admitted May 17, 2011. The annual physical exam was completed on May 15, 2012 by the physician, but it did not include a re-evaluation by the physician as required.
Patient # 7 was admitted February 4, 2010. The annual physical exam was completed on March 1, 2012, (almost one month late), by the physician, but it did not include a re-evaluation by the physician as required.
Patient # 11 was admitted June 8, 2009. The annual physical exam was completed on August 1, 2012, (almost two months late), by the physician, but it did not include a re-evaluation by the physician as required.
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Plan of Correction
The Program Director will create a document highlighting the necessity for the written Physician annual re-evaluation to include appropriate wording to reflect the Physicians opinion on the patients need to either continue and/or discontinue treatment at this level of care.
This will be presented by the Program Director to the medical staff on site; scheduled meeting for December 11, 2012. This document will be signed by all parties acknowledging that this training and review of the necessity to document the treatment planning opinion of the Physician has been completed and that all parties understand the steps to be taken to ensure compliance to this policy.
A review of notations made by the Physician towards this end will be audited by the Program Director and the Nurse Manager; the latter to be included in the aforementioned training as well.
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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, the facility failed to document the attempt or completion of patient follow up contact in eight of nine patient records reviewed.
The findings include:
Twenty patient records were reviewed November 13-15, 2012. Eight patient records required documentation of an attempt or completion of a follow up contact. Seven patient records had no documentation of any attempt to follow up with the patient after discharge.
Patient # 12 was discharged as administratively on July 19, 2012. There was no documentation of a follow up attempt at the time of the monitoring.
Patient # 13 was discharged as an administrative detoxification on September 18, 2012. There was no documentation of a follow up attempt at the time of the monitoring.
Patient # 14 was discharged as administratively on June 23, 2012. There was no documentation of a follow up attempt at the time of the monitoring.
Patient # 15 was discharged as administratively on July 6, 2012. There was no documentation of a follow up attempt at the time of the monitoring.
Patient # 16 was discharged as a transfer on October 1, 2012. There was no documentation of a follow up attempt at the time of the monitoring.
Patient # 17 was discharged as a transfer on July 2, 2012. There was no documentation of a follow up attempt at the time of the monitoring.
Patient # 18 was discharged as completed treatment on September 27, 2012. There was no documentation of a follow up attempt at the time of the monitoring.
Patient # 19 was discharged as completed treatment on October 12, 2012. There was no documentation of a follow up attempt at the time of the monitoring.
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Plan of Correction
Follow up contacts post discharge has been reviewed as part of new staff orientation and acclimation; along with being reviewed during group supervision sessions on December 10, 2012.
At the time of this deficiency a number of newly hired clinical and administrative staff had come on board.
A review of the follow up contacts necessary will be completed and include the addition of the Administrative and Office assistant personnel. The completion of this task will be assigned to both departments to ensure greater coverage and timely completion of this regulation.
The Program Director will audit the timely completion of this task utilizing the SMART report of services due. Additionally, the Program Director will work with the Clinical Team to create an excel spreadsheet that will track the specific services due to include discharges and follow up contacts. This will provide additional assistance in timely completions and documentation of such tasks by both department staff.
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715.23(d)(2) 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.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Based on a review of patient records, the facility failed to document the progress or lack of progress in achieving the goal statements from the prior treatment plan, or within 60 days in four of six patient records.
The findings include:
Twenty patient records were reviewed November 13-15, 2012. Six patient records were reviewed for treatment plan update documentation.
Patient # 2 was admitted September 16, 2010. Treatment plan updates for the past six months, or three review periods, were reviewed. The progress statements did not reflect the goals and objectives and the same progress statements were repeated for each review.
Patient # 6 was admitted May 17, 2012. Treatment plan updates for the past six months, or three review periods, were reviewed. The progress statements contained the same progress statements were repeated for each review, June 5, 2012, September 10, 2012 and October 20, 2012.
Patient # 13 was admitted July 29, 2010. Treatment plan updates for the past six months, or three review periods, were reviewed. The progress statements did not reflect the goals and objectives established.
Patient # 20 was admitted April 11, 2011. Treatment plan updates for the past six months, or three review periods were reviewed. An update was completed June 1, 2012 and then another September 4, 2012, more than 30 days late.
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Plan of Correction
The Program/Clinical Director will complete trainings surrounding the development, creation, and progress notation of treatment plans.
This training will be offered to all clinical staff within the program in Pottstown as well as offers extended to other programs within the Project. The date to be determined within 60 days of this draft.
The Program Director will conduct more thorough reviews of submitted treatment plans. Once the appointment of the Lead Clinician is in place this will become a joint effort between both the Program Director and Lead Clinician.
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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 the review of administrative documentation, the facility failed to provide documentation of an incident with the potential for negative community reaction to the Department as required.
The findings include:
Administrative documentation that included the unusual incident reports was reviewed November 13, 2012. It was noted the facility had documentation of an incident August 4, 2012 that identified a patient with a history of abusing benzodiazapine being in a motor vehicle accident that injured four people and a building. This unusual incident was not reported to the Department as required.
This was discussed with facility staff who acknowledged it was not sent.
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Plan of Correction
The Program Director will complete any and all notifications to the Department as dictated in 715.28(c)(1-5).
These notifications will also be filed within the specific patient chart along with the evidence that said document has been provided to the Department.
A review of regulation 715.28(c)(1-5) will also be reviewed for all staff to ensure compliance and knowledge to this regulation.
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