INITIAL COMMENTS
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This report is a result of a complaint investigation conducted by staff from the Division of Drug and Alcohol Program Licensure on July 18, 2008. Based on the findings, 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 and a plan of correction is due August 21, 2008.
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Plan of Correction
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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
Based on a review of 9 patient records on July 18, 2008, 5 were reviewed for compliance with drug urinalysis testing. The facility failed to ensure the completion of random drug-screening urinalysis at least monthly in one patient record, # 4; the patient record revealed no documentation of drug urinalysis testing since May 2008.
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Plan of Correction
At the time of the inspection the urinalysis testing had been complete but the counselor failed to file the results in a timely manner. This issue was addressed with all staff by the Program Director. All filing will be done within 24 hours. This will be monitored for compliance through weekly chart monitors of 4-5 random charts by the program director. |
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
Based on a review of 9 patient records on July 18, 2008, 5 were reviewed for documentation of take-home privileges. The facility failed to document the physician's determination for the take-home status change for patient # 4.
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Plan of Correction
The nurse will now provide the doctor with the proper documentation and double check that it is completed properly and in a timely manner. The nurse will ensure that a progress note and a physician order is completed on each change in status. This will be monitored through weekly chart monitors of the Program Director. |
715.16(a)(4) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(4) A narcotic treatment physician may rescind take-home medication privileges.
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Observations
Based on a review of 9 patient records on July 18, 2008, 5 patient records were reviewed for take-home privilege status. The facility failed to document that the physician rescinded the take-home medication privileges for patient # 4. Patient record # 4 documented that the patient's take-home privileges were rescinded by staff; but there was no documentation of an order by the physician to rescind the take-home privileges.
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Plan of Correction
The rescind of privileges form had been signed but had not been filed by the counselor. This was addressed with all staff by the Program Director. All staff will have filing completed within 24 hours of receipt. Weekly chart monitors will be done by the Program Director for compliance. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on a review of 9 patient records on July 18, 2008, the methadone doses were reviewed in 5 patient records. The computer system failed to identify that patients # 1 and 14 had been given a take-home dose for that day and the patients were re-dosed at the Narcotic Treatment Program resulting in the patients being medicated twice on the same day.
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Plan of Correction
Foundations is consulting with AMS daily to determine why the permissive within the AMS program is allowing these specific patients to have the option to dose twice. Foundations will rectify this issue immediately once identified between Foundations and AMS. Foundations will have consulted with AMS by September 2, 2008. |
715.17(c)(4)(i-viii) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(4) Method for control and accountability of drugs. A narcotic treatment program shall develop and implement written policies and procedures regarding who is authorized to remove drugs from the storage area and the method for accounting for all stored drugs. An agent or other drug prescribed or administered shall be documented on an individual medication record or sheet in a manner sufficient to maintain an accurate accounting of medication at all times and shall include:
(i) The name of the medication.
(ii) The date prescribed.
(iii) The dosage.
(iv) The frequency.
(v) The route of administration.
(vi) The date and time administered.
(vii) The name of the person administering the medication.
(viii) The take-home schedule, if applicable.
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Observations
Based on a review of 9 patient records and facility policies and procedures on July 18, 2008, the facility failed to follow their policy and procedure to provide accountability for two patient records. Patients # 1 and 4 received double doses of methadone. The facility method for control and accountability failed to prevent the double dosing of these patients.
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Plan of Correction
Foundations is consulting with AMS daily to determine why the permissive within the AMS program allowed these specific patients to have the option to dose twice. Foundations will rectify this issue immediately once identified between Foundations and AMS. Foundations will have consulted with AMS by September 2, 2008. |
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
Based on a review of 9 patient records on July 18, 2008, all were reviewed for compliance with the requirements for psychotherapy. The facility failed to document that patients # 2, 4, 5, 6, 7, 8 and 9 received a minimum of 2.5 hours of psychotherapy per month as required.
Patient # 2 received 1.5 hours in June 2008 and 2.25 hours in May 2008.
Patient # 4 had no psychotherapy documented since March 2008.
Patient # 5 received 1.25 hours in June 2008, 2.75 hours in May 2008 and 1.25 hours in April 2008.
Patient # 6 received 0.75 hours in June 2008, zero hours in May 2008 and 1.25 hours in April 2008.
Patient # 7 received 1.0 hour in June 2008, 0.50 hour in May 2008 and 0.50 hour in April 2008.
Patient #8 received 2.5 hours in June 2008, 2.5 hours in may 2008 and 1.25 hours in April 2008.
Patient # 9 had no psychotherapy documented since May 2008.
This is a repeat violation. The facility was cited for non compliance with this standard during the methadone monitoring inspection of September 27, 2008 and during the methadone monitoring inspection of March 27, 2008. The facility has not demonstrated compliance with this standard for two consecutive methadone monitoring inspections and a subsequent complaint investigation.
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Plan of Correction
Client hours were higher than documented due to counselors note typing their notes or filing in a timely manner. This was addressed with all staff regarding time lines on August 6, 2008. All notes and filing will be done within 24 hours of client appointments. This will be monitored weekly by the Program Director through weekly chart reviews. This will be effective immediately. |
715.21 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.
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Observations
Based on a review of 9 patient records and facility policies and procedures on July 18, 2008, the facility failed to make every effort to retain two patients in treatment prior to their involuntarily termination, specifically patients # 2 and 5. The facility failed to make any effort to retain the patients. Facility documentation revealed the patients did not threaten or assault staff.
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Plan of Correction
Foundations Medical Services has adjusted it policy to allow clients to call if they are going to be late and the pumps will be held open for a reasonable timeframe. On a daily basis the nurses will not shut the pumps down for 15 minutes past the closing of dosing hours in the event that a true emergency occurs. This is effective immediately. |
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 9 patient records on July 18, 2008, two were reviewed for compliance with the involuntary termination regulations. The facility failed to follow the standards when they involuntarily and immediately discharged patients #2 and 5 after a July 13, 2008 incident involving the two patients.
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Plan of Correction
At a hearing on Monday, August 11, 2008 the charge of terroristic threats was dropped for both clients. They were offered readmittance into the facility and the female declined but the male stated he would consider it. |
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 a review of 9 patient records on July 18, 2008, 3 were reviewed for compliance with the requirement for annual physical examinations. The facility failed to document an annual physical examination for patient # 4; the annual physical examination was due to be completed by June 2008.
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Plan of Correction
Upon review of the Policy and Procedure manaul the counselor's will be responsible to schedule the annual physical. This appointment will be scheduled 1 month prior to the due date for and appointment to be completed within one week of the annual review date. This will be monitored weekly by the Program Direcftor through weekly chart monitors. This is effective immediately. |
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 a review of 9 patient records on July 18, 2008, all were required to maintain compliance with the requirement that counselor notes regarding patient progress and status be documented. The facility failed to provide current clinical documentation in the patient records for patients # 4 and 9. Patient record # 4 contained no clinical documentation since 3/24/08 and patient record # 9 had no clinical documentation since 5/5/08.
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Plan of Correction
Counselor failed to file clinical documentation in a timely manner. This was addressed by the Program Director. All documentation is to be filed within 24 hours of contact or receipt of document. Program Director will continue to monitor through weekly chart monitors. |
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
Based on a review of 9 patient records on July 18, 2008, 8 were reviewed for records of services . The facility failed to maintain patient records of services that were consistent with the clinical documentation in four of eight patient records, specifically patient records # 2, 4, 6 and 8. Patient records # 4, 6 and 8 identified counselor sessions in the record of services but had no counselor notes that coincided with the record of services.
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Plan of Correction
The counselor has been addressed on timeliness of filing of clinical notes. These notes will be in the file within 24 hours of session with the client. Program Director will monitor through weekly chart monitors. |
715.23(b)(14) LICENSURE Patient records
(b) Each patient file shall include the following information:
(14) Case consultation notes regarding the patient.
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Observations
Based on a review of 9 patient records on July 18, 2008, 4 patient records were reviewed for compliance with case consultation requirements. The facility failed to document case consults for patient # 1 as the last quarterly consult was completed on 3/13/07.
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Plan of Correction
This was addressed with the counseling staff regarding guidelines for case consults. All staff were retrained as to the regulations. The will be monitored ongoing by the Program Director through weekly chart monitors. |
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
Based on a review of 9 patient records on July 18. 2008, 3 were reviewed for annual evaluation requirements. The facility failed to document the physician's signature on the June 2008 annual evaluation in patient record # 4. Additionally, patient # 1 had not had an annual evaluation since June 2007.
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Plan of Correction
The Physician Signature line has been added to the annual evaluation form to ensure that all evaluations are signed by the doctor. The counselors have been given a tracking took to track when the annual evaluations are due and will have these completed prior to the date it is due and signed by the physician within the same time frame. This will be monitored by the Program Director through weekly chart monitors. |
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 9 patient records on July 18, 2008, 7 were reviewed for treatment plan requirements. The facility failed to complete updates in a timely manner as the last update for patient # 5 was completed on 5/03/08 and was overdue. The last update for patient #3 was documented on 3/20/08 and was overdue. The treatment plan for patient #6 was not documented and was overdue as of 7/9/08. Additionally, treatment plans were not updated to reflect changes and needs that developed in the patients' lives; specifically, patient # 5 became homeless in June 2008 but the situation was not addressed in the treatment plan and patient # 7 had attendance issues that were not addressed in the treatment plan.
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Plan of Correction
Counselors have been given a tracking device to know when treatment plans are due. The content of treatment planning has been reviewed by the Program Director. The use of a master problem list is in the process of being implemented to aid the counselors in ensuring that all problem areas are addressed. The Program Director will monitor this through weekly chart monitors for compliance. |
715.23(e) LICENSURE Patient records
(e) Patient file records, information and documentation shall be legible, accurate, complete, written in English and maintained on standardized forms or electronically.
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Observations
Based on a review of 9 patient records on July 18, 2008, all nine records were reviewed for compliance with complete patient records. The facility failed to maintain a complete record in 9 of 9 cases. Specifically, documentation of counselor notes was not current in patient records # 2, 3, 8 and 9 and treatment plans and updates were not current in patient records # 1, 3, 4, 5, 6, 7 and 9. Additionally, the facility failed to have the physician's signature on the annual evaluation of patient # 4. Further, not all documentation was entered into patient records in a timely fashion as identified by a counselor who provided documentation for patient # 2 at the time of the monitoring visit; the information was late and had been written and printed on the date of the onsite inspection.
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Plan of Correction
Program Director met with staff on 8/6/08 and informed them all progress notes must be documented and filed in the client's chart within 24 hours of the session/occurrence.
A new tracking form was implemented on 8/6/08. This tracking system will alert the counselor a week in advance of any upcoming treatment plan reviews/updates needed.
The new treatment plan/treatment plan update form that was implemented last month requires that any goals and objectives not completed on the previous treatment plan be carried over and a new treatment plan must be devised. This will occur every 60 days.
The physician signature has been added to the annual evaluation. Program Director informed Physician of the importance of fully completing all documentation and signatures as per regulations.
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