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 March 25, 26, and 27, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Foundations Medical services, LLC 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 plan of correction is due on April 24, 2008.
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Plan of Correction
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715.6(a) LICENSURE Physician staffing
(a) A narcotic treatment program shall designate a medical director to assume responsibility for administering all medical services performed by the narcotic treatment program
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Observations
Based on documentation and staffing review, the facility failed to provide adequate services by a medical director; specifically, the medical director was on site a cumulative total of 2.5 hours during the months of November and December, 2007 and January, February, and March, 2008.
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Plan of Correction
Dr. Giordano has been interviewed and selected to be the interim medical director at Foundations Medical Services. His training plan has been developed and is awaiting approval by the Department of Health. If approved, Dr. Giordano will begin services and training under the direction of Dr. Roemer and Dr Styles, the latter as indicated on 5/28/08 . Dr. Giordano will be on site at the clinic 1 hour per week for every 10 clients on service. A schedule has been arranged to accomodate a client capacity of 175. His time spent at the clinic as well as his services and documentation will be monitored by Program Director and Director of Pharmacotherapy Services. Corrective actions will be completed on 5/28/08 |
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.
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Observations
Based on a review of 18 patient records, the facility failed to document the physician's determination of a one year history of addiction; specifically patient # 1, 5 and 17 did not contain the required documentation.
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Plan of Correction
A interim medical director is in the process of being hired at Foundations Medical Services and will be trained accordingly. He is to begin services on 5/28/08.
Also, a seperate "Determination of Opiate Dependency" form has been designed and implemented immediately. The Program Director is monitoring 5 charts a week to ensure compliancy and will continue to do so. |
715.9(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
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Observations
Based on random review of 8 patient records, the facility failed to, with patient consent, contact a previous narcotic treatment facility for the patient #1's prior treatment history.
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Plan of Correction
Previously the counselors were only requesting information on direct transfers from other facilities. The Program Director has instructed staff to request information from any client who has previously been in an NTP and document all attempts.
Four to five charts are pulled randomly every month for monitoring by the director and a chart monitoring workgroup has been established by staff to ensure compliance. |
715.10(c) LICENSURE Pregnant patients
(c) Counseling records and other appropriate patients records shall reflect the nature of prenatal support provided by the narcotic treatment program.
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Observations
Based on a review of 3 patient records, the facility failed to ensure that pregnant patients' records reflected the nature of prenatal support provided by the narcotic treatment program in two of three patient records, #6 and 16, as neither file contained documentation of ongoing clinical and medical supports that addressed these patients' pregnancies and the prenatal supports provided by the facility.
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Plan of Correction
The clients will see the doctor within one week of a positive pregnancy test and then every three months until termination or delivery of the baby. The client will then have a three month postpartum visit with the doctor. The counselor will do a new treatment plan in regards to prenatal care within one week of a positive pregnancy test. The Program Director will choose 2 charts of pregnant females monthly to review. |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on a random review of 10 patient records, the facility failed to document that the physician reviewed methadone dose levels at least twice a year for patient # 2; specifically, the physician reviewed the patient's dosing levels one time during the past year.
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Plan of Correction
Dr. Giordano has been interviewed and selected to be the interim medical director at Foundations Medical Services. His training plan has been developed and is awaiting approval by the Department of Health. If approved, Dr. Giordano will begin services and training under the direction of Dr. Roemer and Dr Styles, the latter as indicated on 5/28/08 . Dr. Giordano will be on site at the clinic 1 hour per week for every 10 clients on service. A schedule has been arranged to accomodate a client capacity of 175. His time spent at the clinic as well as his services and documentation will be monitored by Program Director and Director of Pharmacotherapy Services. Corrective actions will be completed on 5/28/08.
The Nursing staff will keep a schedule for the doctor to identify who is due for a review. The nursing staff will notify client at least 2 days in advance of scheduled review with doctor.
A random review of 4-5 charts a month will be completed to monitor compliance. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of 10 patient records, the facility failed to document that a consultation took place between the physician's assistant who completed the initial physical for patient # 6 and the physician who ordered the methadone.
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Plan of Correction
A Physician Assistant Communication Sheet was implemented in October 2007 in which the Physician Assistant will complete a physical for a patient. The Physician Assistant will then complete the Communication Sheet which includes the patient name, date of birth, date of exam, social security number, PA evaluation and comments and the physician review and comments. Verbal communication between the PA and the physician occurs within 24 hours of seeing the patient and prior to the client being admitted and dosed. This documentation is placed in the chart with the physical exam paperwork.
The process is being monitored by weekly chart monitors of 4-5 random charts by the Program Director. It is also monitored monthly by peer reviews of another physician. |
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 policy and procedure and staff interviews, the facility failed to have the physician consistently make the final determination regarding take-home privileges; specifically, the policy and procedure indicated a system for staff review prior to review by the physician that included a determination by the director to withhold patient requests for take-homes that were deemed to not be appropriate for take-home privileges from the doctor. The physician did not participate in the staff review.
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Plan of Correction
All take home privilege requests will be submitted to the attending physician for final determination. The Program Director revisited this policy and procedure with the entire staff at Foundations on 4/16/08. |
715.16(c)(1)(i-iv) LICENSURE Take-home privileges
(c) A narcotic treatment program shall require a patient to come to the narcotic treatment program for observation daily or at least 6 days a week for comprehensive maintenance treatment, unless a patient is permitted to receive take-home medication as follows:
(1) A narcotic treatment program may permit a patient to reduce attendance at the narcotic treatment program for observation to three times weekly and receive no more than a 2-day take-home supply of medication when, in the reasonable clinical judgment of the narcotic treatment physician, which is documented in the patient record:
(i) A patient demonstrates satisfactory adherence to narcotic treatment program rules for at least 3 months.
(ii) A patient demonstrates substantial progress in rehabilitation.
(iii) A patient demonstrates responsibility in handling narcotic drugs.
(iv) A patient demonstrates that rehabilitation progress would improve by decreasing the frequency of attendance for observation.
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Observations
Based on a review of ten patient records, the facility failed to consider patient # 15's documented lack of progress in treatment in the decision to increase take-home privileges; specifically, the patient's number of take-homes was increased to three times per week without consideration of the patient's lack of treatment progress as documented in the progress notes.
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Plan of Correction
The counselor will review all take home requests with the program director to ensure the client meets the eight point criteria and that they are working on their treatment plan goals and objectives. This will then be reviewed with the physician within 24 hours for approval. This process was reviewed with the staff on 4/9/08. |
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 observation and staff interview on March 26, 2008, the nurse was observed answering the telephone while in the process of dosing a patient; said action failed to provide a practice of methadone administration that was free of disruption.
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Plan of Correction
On 4/16/08 the nursing staff were notified that they are not to perform any other functions while dosing a patient. To minimize disruption external phone calls were redirected from the nursing phones on 4/24/08. The entire staff was notified on 4/16/08 at staff meeting that to minimize disruption of the nursing staff they are not to walk up to the dosing window, call nursing staff in excess on the phone or provide any other disruptions which could cause a medication error. These practices are effective immediately. |
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 patient records, the facility failed to provide each patient the minimal average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment in 5 of 18 records, specifically # 4, 5, 6, 7, 15 and 16. In record #4, there was no documentation of patient contact since 1/22/08. Record #5 revealed that the patient received .5 hours in January 2008, 2.25 hours in February 2008 and 1 hour in March 2008. In record # 15, the patient received 1.5 hours in November 2007, 2.25 hours in December 2007, 1 hour in January 2008 and 2 hours in February 2008 and patient # 16 had no hours in February 2008 and 2 hours in March 2008.
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Plan of Correction
Two days per month the dosing hours are extended and groups are held from 5:30 am - 2:00 pm or as needed. These groups are held for those clients who regularly miss their scheduled sessions. An absolute hold is placed on the client and they are not permitted to dose until they attend group. Clients are informed in advance of when the sessions are scheduled and that they will not be permitted to dose until they attend group.
Effective immediately.
This initiative will be monitored monthly by the director and the chart monitoring work group through review of client caseload.
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715..23(b)(1) LICENSURE Patient records
(b) Each patient file shall include the following information:
(1) A complete personal history.
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Observations
Based on a review of patient records, the facility failed to document a complete personal history in 3 of 4 records, specifically #1, 5 and 6. The personal histories contained either one-word answers with no further clarification or questions left unanswered.
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Plan of Correction
Counselor will complete this form with the client at their first session. the counselor will then be able to prompt the client for more detailed information.
A training by the Program Director is scheduled for 5/2/08 to all staff completing this form with the clients.
This will be monitored weekly by the program director and the chart monitoring staff who will look at approximately 4-5 charts per week. |
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 random review of 18 patient records, the facility failed to provide the required information regarding the patient's progress and status in the clinical notes for patients # 6, 15, and 16. The Data, Assessment, Plan (DAP) format was utilized. The "A" (assessment) failed to consistently provide a clinical assessment of the patient's progress and the "P" (plan) contained a generic note that referred to an unspecified future contact. Additionally, patient # 4 record had no progress note documentation since January 22, 2008.
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Plan of Correction
The Program Director will retrain the staff on how to write a DAP note in the correct format. Stressing the need for detail. This training will take place on 5/8/08.
The Program Director and the chart monitoring team will review 4-5 charts weekly to ensure compliance with this standard. |
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 patient records, the facility failed to ensure that patient record of services were complete and current in 2 of 11 patient records reviewed, specifically, patients 4 and 6. Patient #4 was missing the services provided in February and March; patient record # 6 contained a record of services that was not consistent with progress note documentation.
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Plan of Correction
The Program Director will retrain the staff on how to complete this form and specifically address the need and importance of the record of service to be consistent with the progress note documentation. Counselors will also be required to complete the record of service each time they have contact with a client. The record of service will be completed by the end of the day the contact took place. Compliance will be met by May 8, 2008. Compliance will be monitored by the Program Director and the chart monitoring workgroup through weekly chart monitors of 4-5 charts. |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on review of 10 patient records, the facility failed to provide an evaluative assessment of patients # 1, 5, 6, 7, and 17 that included the counselor's clinical analysis of the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, patient's attitude toward treatment and overall impressions based on the information provided by the patients. Instead, the psychosocial evaluations of the patients consisted primarily of the repetition of the history and statements reported by the patient.
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Plan of Correction
Program Director to retrain the staff on 4/29/08. A sample training document was created and will be distributed to the staff for reference on how to write a psychosocial evaluation. The Program Director and the chart monitoring workgroup will do 4-5 chart monitors weekly to ensure compliance with this standard. |
715.23(b)(22) LICENSURE Patient records
(b) Each patient file shall include the following information:
(22) Aftercare plan, if applicable.
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Observations
Based on a review of patient records, the facility failed to document a complete aftercare plan in 3 of 9 records, specifically #8, 12 and 18. The aftercare plans in these patient records did not include personal goals and patient #8 was discharged on 3/7/08 but had an aftercare plan that was dated 4/12/07.
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Plan of Correction
The Program Director will retrain the staff on these forms on 5/8/08. There are two forms that will now need to be filled out. The one form will be filled out by the client. This will detail their own plans to maintain their sobriety, deal with family and social stressors, maintain physical wellbeing, etc. The second form will be completed by the counselor which outlines any aftercare appointments that have been set up as well as action steps with dates to continue with their recovery program. Prior to discharge the client and counselor will review the plans together and make any updates or changes as needed. This process will be monitored in weekly supervision with the counselors and Program Director. |
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 a review of patient records, the facility failed to document a complete discharge summary in 8 of 9 records, specifically # 5, 10, 11, 12, 13, 14, 17 and 18. The discharge summaries failed to document the patient's reason for treatment, progress made during treatment, and reason for treatment termination.
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Plan of Correction
Program Director instructed/educated staff that they need to include to include documentation in the client's discharge summary to include the client's reason for seeking treatment, services provided and the client's specific response to treatment. The discharge summary form has been revised by the forms committee to make it more user friendly and definitive. The Program Director and the chart monitoring workgroup with pull 4-5 charts randomly a month for monitoring of compliance. |
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 a review of the policy and procedure manual and patient record reviews, the facility's policy to address follow-up is inconsistent as it provided two separate time frames for follow-up in the the policy manual; specifically, in one statement follow-up 30 days following discharge is addressed while in another section it is stated that follow-up will occur at six months and 12 months.
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Plan of Correction
The Policy and Procedure manual will be revised to reflect follow up to occur 30 days following discharge of the client by the Program Director. The counselors have been educated/trained by the Program Director on 4/16/08 of the changes to this policy and procedure. |
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 patient records, the facility failed to ensure that annual evaluations were completed as required. Patient record # 2, 3, 4, and 7 contained minimal information and they were not signed, as required, by the medical director.
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Plan of Correction
A interim medical director is in the process of being hired at Foundations Medical Services and will be trained accordingly. He is to begin services on 5/28/08.
The nursing team will keep track of which clients are due for the annual review in conjunction with the counselors. The nursing staff will notify the client of this appointment with the doctor. The doctor will receive adequate training by Dr. Rhomer at Dolminis. Continued monitoring for compliance will be completed by the Program Director by means of 4-5 chart monitors weekly. |
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.
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Observations
Based on the review of 18 patient records, the facility failed to develop treatment plans that contained short term goals with measurable steps. Further, the treatment plans failed to identify support services needed by the patient. Of the patient records reviewed, patient records # 1, 2, 3,4,5, 6, 7, and 17 contained vague, non-specific steps to reach the goals and the time frames were generalized rather than realistically specific to the action step and support services were not specified in the documentation.
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Plan of Correction
Support services has been added to the treatment plan and the counselor must circle which services are recommended. The importance of documenting type and frequency of services will also be addressed. Staff will be shown how to break down a goal into objectives that are identifiable and measurable. The Program Director will retrain counselors in this area on May 5, 2008. The Program Director and the chart monitoring workgroup will review 4-5 charts randomly every week for compliance. |
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 treatment plan updates based on the patient's progress as it related to the goals stated in the comprehensive treatment plan in 3 of 18 records, specifically #6, 15 and 16. The treatment plan updates failed to address patient specific goals and when new goals were added no interventions or measurable action steps were documented. Additionally, patients # 3 and 4 did not not have recent updates as the last documentation was November 2007.
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Plan of Correction
Training will be completed on how to write measurable goals and objective based on the national outcome measures. Clinicians will also be retrained on completing treatment plan updates and documenting whether progress or lack of progress has been made. Clinicians have been instructed to refrain from implementing treatment plans longer than 3 months out. New treatment plans can be added and implemented at a later date as needed. Director has reminded counselors the regulation requiring all treatment plans are to be updated at least every 60 days.
Program Director to retrain staff in this area on May 5, 2008. Continued performance monitoring will take place through random monitoring of 4-5 charts weekly by the Program Director.
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