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 January 27, 2009 by staff from the Division of 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 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and a plan of correction is due on February 27, 2009.
|
Plan of Correction
|
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.
|
Observations
Based on a review of patient records, the facility failed to document a face-to-face determination occurred
prior to a patient admission in one of one records.
The findings include:
Five patient records were reviewed on January 27, 2009. One record was required to provide documentation of the physician's face-face assessment of the patient prior to the admission of patient Documentation in record # 3 reported that the patient was assessed by the physician on 1/08/09; the documentation that related to the face-to-face assessment was not signed or attested by the physician until 1/22/09. The actual date of the face-to-face assessment could not be determined due to the conflicting information.
|
Plan of Correction
The face to face assessment of the patient was completed on 1-8-09. The documentation for this service was completed late by the physician on 1-22-09. It should have been noted in the documentation that it was late and the reason for the late note. This deficiency was reviewed with the physician on 2-19-09. In the future the physician will document the face to face assessment on the date the assessment is made. In the case of a late note, it will be documented as such and the reasoning for the late note. Physician assessment documentation will be reviewed on a weekly basis by the Program Director for the following three months. Thereafter random reviews will be done monthly.
|
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.
|
Observations
Based on a review of the facility's policy and procedure regarding involuntary terminations and patient documentation signed by patients at admission, the facility developed policies that addressed involuntary terminations that exceeded the standard criteria for involuntary termination.
The findings include:
A review of the policy and procedure and five patient records revealed that, upon admission, patients signed facility issued agreements that stipulated involuntary discharge for financial noncompliance and failure to cooperate with urinalysis testing. These reasons were not consistent with the regulations for involuntary termination.
|
Plan of Correction
The forms were revised to reflect the policies and procedures of the facility on 1-29-09. The inaccurate forms have been destroyed and the new forms have been implemented. Discharges are not done for failure to cooperate with urinalysis testing or financial non-compliance.
|
715..23(b)(1) LICENSURE Patient records
(b) Each patient file shall include the following information:
(1) A complete personal history.
|
Observations
Based on a review of five patient records, the facility failed to provide complete personal histories in 2 of three patient records.
The findings include:
Five patient records were reviewed on January 27, 2009; three patient records were reviewed for patient history content. Patient record # 2 revealed the patient had been sexually molested; no further information was identified to address age, whether the molestation was a singular event or pattern, knowledge about perpetrator and general impact of the molestation. Patient record # 4 contained documentation of a personal history that provided one word answers, failing to provide detailed and complete information regarding the patient.
|
Plan of Correction
The Clinical Director reviewed the deficiencies in documenting the personal histories with the counselor on 1-28-09. The clinical director provided supervision and guidance on the proper completion of the personal history and the information that is required on 1-28-09. Personal histories will all be reviewed and approved by the clinical director on an ongoing basis. Monthly random audits will be conducted by the Program Director for the next three months then random quarterly audits thereafter. |
715.23(b)(11) LICENSURE Patient records
(b) Each patient file shall include the following information:
(11) Counselor notes regarding patient progress and status.
|
Observations
Based on a review of patient records, the facility failed to consistently document individual counselor notes in two of four records.
The findings include:
Five patient records were reviewed on January 27, 2009. Counselor notes were required in all four patient records. Counselor notes that addressed the patient's admission to treatment were missing in two records, # 3 & 4.
|
Plan of Correction
The Clinical Director reviewed the deficiency with the counselor on 1-28-09. The counselor will complete an individual counseling note for when the biopsychosocial assessment is completed. This note will document in DAP format the encounter. The Clinical director will review the records weekly to ensure that individual counseling notes are completed when the biopsychosocial assessment is done. |
715.23(b)(13) LICENSURE Patient records
(b) Each patient file shall include the following information:
(13) Patient record of services.
|
Observations
Based on a review of five patient records, the facility failed to provide a record of services for each patient in four of four records reviewed.
The findings include:
Five patient records were reviewed on January 27, 2009; four records were required to contain a record of services. Records # 1, 2, 3 and 4 failed to include a record of services. Staff interviewed reported there was a record of services contained in the electronic component of each patient's record but were unable to retrieve this information.
|
Plan of Correction
The record of service is available in the electronic recordkeeping system. All staff has been trained on how to access the record of services on 1-28-09. The Program Director will be responsible for ensuring that all staff are trained on how to access the record of service report on an ongoing basis. |
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 a review of patient records, the facility failed to complete psychosocial evaluations in three of three patient records.
The findings include:
Based on a review of five patient records, four were reviewed for psychosocial evaluation content. Patient records 1, 2 and 4 failed to provide a psychosocial evaluation that included a clinical assessment of the patient.
|
Plan of Correction
Deficiencies in the documentation of the psychosocial evaluation were reviewed with the counselor on 1-28-09. The Clinical Director reviewed the necessary components of the psychosocial evaluation with the counselor on 1-28-09. All Psychosocial evaluations will be reviewed and approved by the clinical director on an ongoing basis to ensure that the necessary components are documented. Monthly random audits will be conducted by the Program Director for the next three months then random quarterly audits thereafter.
|
715.23(d) 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.
|
Observations
Based on the review of patient records, the narcotic treatment program failed to document realistic short and long-term treatment goals in one of three patient records.
The findings include:
Five patient records were reviewed on January 27, 2009. Treatment plans with realistic short and long-term treatment goals were required in three patient records. The narcotic treatment program did not document short and long-term goals that were individualized for the patient in patient record #1.
|
Plan of Correction
The Deficiency was reviewed with the counselor on 1-28-09. The required components of a treatment plan were reviewed with the counselor. Treatment plans will be developed individually based on the information obtained from the biopsychosocial assessment. The Clinical Director will review and approve all treatment plans to ensure that they meet the regulations. The Program Director will randomly review treatment plans on a quarterly basis.
|
715.23(d)(1) 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.
(1) The treatment plan shall identify the behavioral tasks a patient shall perform to complete each short-term goal.
|
Observations
Based on the review of patient records, the narcotic treatment program failed to document treatment plans in three of three patient records.
The findings include:
Five patient records were reviewed on January 27, 2009. Treatment plans were required in three patient records. The failed to document support services and type and frequency of services in records # 1 & 3.
|
Plan of Correction
Deficiencies in the documentation of the treatment plan were reviewed with the counselor on 1-28-09 by the clinical Director. The Clinical director provided guidance and supervision on treatment planning and the required components of the treatment plan. The Clinical Director will review and approve of all treatment plans on an ongoing basis to ensure that they document all items to include supportive services. |