INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use narcotic agents, specifically methadone and buprenorphine in the treatment of narcotic addiction. This inspection was conducted on December 2 and 11, 2008 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 and a plan of correction is due on January 15, 2009.
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Plan of Correction
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715.10(d) LICENSURE Pregnant patients
(d) Within 3 months after termination of pregnancy, the narcotic treatment physician shall enter an evaluation of the patient 's treatment status into her record and state whether she should remain in comprehensive maintenance treatment or receive detoxification treatment.
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Observations
Based on the review of patient records, the narcotic treatment program failed to document, within three months after the termination of pregnancy, whether or not the patient should continue maintenance or receive detoxification treatment in one of one patient record.
The findings include:
Twelve patient records were reviewed December 11, 2008. An evaluation of the patient's treatment status within three months after termination of pregnancy was required in one patient record. The narcotic treatment program, specifically the physician, did not document this evaluation that was due on November 7, 2008 based on the patient's termination of pregnancy on August 7, 2008 in patient record #6.
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Plan of Correction
Once the patient notifies her counselor of her pregnancy and estimated delivery date the physician's extender will be notified by the patient's counselor. The physician extender will keep a spreadsheet listing all pregnant patients and the estimated delivery date. Once the patient has delivered her baby and the patient's counselor and the physician extender are informed the physician extender will place a note in the computer to have the patient schedule her post partum appointment within 90 days from the delivery date. The Physician extender will keep these appointments on the spread sheet. |
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 the review of patient records, the narcotic treatment program failed to document all efforts to retain the patient in the program prior to initiating an involuntary termination one of one patient records.
The findings include:
Twelve patient records were reviewed on December 11, 2008. Documentation that an involuntary terminations was initiated only when all other efforts to retain the patient in the program have failed was required in one patient record. The facility did not document the efforts made to retain the patient in patient record #9. The treatment plan and progress notes in the record did not address any efforts to retain the patient in treatment. A case consultation on July 24, 2008 stated that the patient was having difficulty making all scheduled appointments, but appears somewhat motivated toward treatment and recovery. No documentation was presented during the licensing inspection.
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Plan of Correction
The clnical supervisors will address this standard in a meeting on 3/4/09 the standard regarding making all efforts to retain patients in treatment. The clinical supervisors will complete chart reviews on patients identified in 1 on 1 supervision as noncompliant with treatment requirements and at risk of involuntary termination from CTC to ensure that all efforts have been made to retain the patient in treatment and properly documented. These chart reviews will be done weekly for 2 months. Once it is determined that this standard is in compliance random chart reviews will be conducted monthly for the next 3 months. |
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 narcotic treatment program failed to document the results of annual reevaluations by the narcotic treatment physician one of two patient records.
The findings include:
Twelve patient records were reviewed on December 11, 2008. Annual reevaluations by the narcotic treatment physician were required in two patient records. The narcotic treatment program failed to document the results of the annual reevaluation by the narcotic treatment physician in patient record #11.
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Plan of Correction
The 1 file that was missing documentation of the annual reevaluation is being completed on 3/4/09. There is documentation in the computer care plan of the annual History and Physical being completed on 6/30/08 by the MD. The paper annual History and Physical has been misfiled and is unable to be located. The CD will monitor the tracking sheet the DON maintains for compliance monthly to assure that all History and Physicals are being completed and filed in a timely manner. The DON will complete random chart reviews for the next 3 months to assure there is compliance with this area and all annual reevaluations are filed in the charts. |
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
Based on the review of twelve patient records, the narcotic treatment program failed to document progress notes in two of seven patient records.
The findings include:
Twelve patient records were reviewed on December 11, 2008. Progress notes were required in seven patient records. The narcotic treatment program did not document progress notes that included an assessment and plan.
In patient record #6 the individual progress notes did not include the clinician's assessment of the patient. In addition, the group progress notes did not include the clinician's assessment of each participating patient in the group.
In patient record #7 the individual progress notes did not include the clinician's assessment of the patient or a plan. In addition, the group progress notes did not include the clinician's assessment of each participating patient in the group.
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Plan of Correction
A training will be conducted by the clinical supervisors by 1/31/09 on writing DAP notes including the assessment and the plan on individual and group progress notes. Specific examples will be given to all counselors. The clinical supervisors will review random charts on a monthly basis in 1 on 1 supervision to monitor for compliance. |
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, the narcotic treatment program failed to document discharge summaries in one of three patient records.
The findings include:
Twelve patient records were reviewed on November 11, 2008. Discharge summaries were required in three patient records. The narcotic treatment program did not document discharge summaries that included the patient's progress in treatment in patient record #9.
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Plan of Correction
The clinical supervisors will review all discharge summaries upon completion. If patients' progress is noted as missing in this summary the counselor will be asked to complete this portion of the summary before the chart is officially closed. The summary protocol will be reviewed with counselors as necessary in 1 on 1 supervision. |
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.
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Observations
Based on the review of patient records, the narcotic treatment program failed to document realistic short and long-term treatment goals in two of three patient records.
The findings include:
Twelve patient records were reviewed December 11, 2008. 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 records #7 and 10.
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Plan of Correction
A training will be conducted by 1/10/09 by the clinical supervisors. The training will address short and long term goals and how to write them on an individualized basis for patients. The information given by the CRC Health Director of Staff Development in a training in August 2008 will also be rereviewed with all of the counselors. This includes writing short and long term goals. The clinical supervisors will continue to review all treatment plans on a weekly basis and sign them. If plans have been completed incorrectly the clinical supervisors will review them with the counselors and give them 48 hours to make the adjustments and return to them. The adjustment will be reviewed by the clinical supervisors and counselors on a 1 on 1 basis. |