INITIAL COMMENTS
|
This report is a result of an on-site inspection conducted for the approval to use a narcotic agent, specifically methadone, in the treatment of narcotic addiction. This inspection was conducted on April 1 and May 10, 2011 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.
|
Plan of Correction
|
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.
|
Observations
Based on the review of patient records and discussion with administrative staff, the facility failed to ensure a random monthly drug-screening urinalysis was completed in five of nine patient records.
The findings include:
Twenty one patient records were reviewed May 10-12, 2011. Nine patient records were reviewed specifically for monthly random drug-screening urinalysis. Five of the nine patient records did not record at least a monthly drug screen during the months reviewed. Monthly drug screens were reviewed from October 1, 2010 to April 30, 2011.
Patient # 3 was admitted September 28, 2005. A drug-screening urinalysis was not conducted for the month of January 2011.
Patient # 6 was admitted January 31, 2006. A drug-screening urinalysis was not conducted for the months of January and April 2011.
Patient # 12 was admitted April 29, 2009. A drug-screening urinalysis was not conducted for the month of December 2010.
Patient # 19 was admitted January 25, 2001. A drug-screening urinalysis was not conducted for the months of November 2010, January and February 2011.
Patient # 20 was admitted April 21, 2005. A drug-screening urinalysis was not conducted for the month of October 2010.
|
Plan of Correction
M101 - Back in January and February of 2011, we were having some technical problems with our new dispensing system. As a result, some urinalyses were missed. The issue has already been addressed by the Direct of Nursing. Since March 23, 2011, the Direct of Nursing and Clinical supervisor have been verifying on the 15th of every month whether or not a patient has had a urine drug screen for the month or have been scheduled for one. If they had not been schedule, the Direct of Nursing manually scheduled their urinalysis. Also, our IT department has added a component to the dispensing system that gives our Nursing Staff a reminder of the last urine drug screen, which has been another component to help them track monthly drug screens. The Direct of Nursing will continue to ensure that all patients are scheduled monthly for a drug-screening urinalysis. |
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.
|
Observations
Based on a review of patient records and discussion with medical staff, the facility failed to ensure the physician signed verbal orders as required.
The findings include:
Twenty one patient records were reviewed May 10-12, 2011. Two patient records reviewed contained documentation of the physician issuing a verbal order. One of the two patient records had two different verbal orders issued by the physician that were not signed within the required 24 hours.
Patient # 8 was admitted on January 6, 2011. The physician issued a verbal order for an increase on January 7, 2011. The verbal order was signed by the physician on January 11, 2011. The physician issued a verbal order on January 8, 2011 and signed the order on January 11, 2011.
|
Plan of Correction
Beginning on July 1, 2011, all verbal orders will be scanned or faxed to the Medical Director to sign and send back to the facility when he is not physcially in the office. The Director of Nursing will ensure that all verbal orders are sent to the Medical Director for his signature as well as signed and dated by the Medical Director within 24 hours. |
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.
|
Observations
Based on the review of patient records, the facility failed to ensure all of the required patient records are transferred in two of two patient records.
The findings include:
Twenty one patient records were reviewed May 10-12, 2011. Two patient records were transferred to another narcotic treatment program. Two patient records did not transfer the required documentation.
Patient # 10 was admitted June 21, 2010. A consent was signed by the patient on April 26, 2011 to transfer to another narcotic treatment program. The patient was discharged May 7, 2011. There was no documentation the required files were transferred to the receiving treatment program.
Patient # 15 was admitted February 1, 2011. The patient returned to his referring narcotic treatment program and then requested a transfer. The receiving facility requested the required information, but the facility failed to document it was sent.
|
Plan of Correction
One Counselor has been assigned to manage all transfers to our facility from other treatment facilities. This Counselor ensures that all required documentation has been received. The Clinical Supervisor oversees the process to verify that all paperwork has been received from the other treatment facility and verifies that the acceptance to treatment letter has been faxed to the transferring facility to inform them that the patient has been admitted into treatment.
After patient signatures have been obtained, Counselors have begun faxing all documentation listed on our facility transfer consent to release even if the receiving facility has not requested the information. Clinical Supervisor oversees. The Clinical Supervisors have maintained 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 has faxed a letter notifying the other facility of the patient admission date and initial dose. If a patient has been referred out to another facility, the Clinical Supervisors or transfer counselor has faxed over a letter requesting written verification of the patient's admission date and initial dose. All written confirmations are filed in the patients chart along with being documented on the tracking sheet maintained by the Clinical Supervisors.
|
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
|
Observations
Based on the review of patient records, the facility failed to execute an evaluative composite picture of the patient in relationship to the collected historical data in four of five client records.
The findings include:
Twenty two patient records were reviewed May 9-11, 2011. Five patient records were reviewed for the psychosocial evaluation of the historical data collected.
Patient # 4 was admitted March 17, 2011. The psychosocial was a repeat of the data as reported by the patient.
Patient # 7 was admitted April 1, 2011. The psychosocial was a repeat of the data as reported by the patient.
Patient # 8 was admitted January 6, 2011. The psychosocial was a repeat of the data as reported by the patient.
Patient # 15 was admitted February 1, 2011. The psychosocial was a repeat of the data as reported by the patient.
|
Plan of Correction
All psychosocial assessments will be reviewed by Clinical Supervisors prior to be filed in the patient chart to ensure that the Counselors have provided their clinical impressions of the patient and not solely what the patient reported. There will be a training conducted by the Clinical Supervisors by 7/8/2011 to provide specific examples of well written detailed psychosocial assessments that contain a complete evaluative composite of the patient. |