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 methadon, in the treatment of narcotic addiction. This inspection was conducted on June 15-17, 2010 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 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 July 12, 2010.
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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 June 15-17, 2010. 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 in patient record #1.
An interview with the facility director on June 15, 2010, confirmed that there was no documentation that the physician had completed the required evaluation.
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Plan of Correction
This regulation was reviewed by the Medical Director. He will discuss with all physician staffing the correct manner for documentation and specific pregnancy needs by 8/15/10. Ongoing chart monitoring by the nursing staff for compliance will be done monthly. |
715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on the review of patient records, the facility failed to ensure the provision of at least one hour per month of group or individual psychotherapy during the third and fourth year of treatment in two of two patient records reviewed.
The findings include:
Twelve patient records were reviewed June 15-17, 2010. Two patient records reviewed required that the patient received at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. The facility did not document that the patient received the required hours in patient records # 4 and 6.
Patient #4 was admitted to the program on July 10, 2006. The patient will not have 4 years in a methadone clinic until July 10, 2010. The patient is required to have at least 1 hour per month of group or individual psychotherapy. For the month of March 2010, the patient received .50 hours of psychotherapy. The months of April and May 2010 had documented progress notes, however the length of the counseling sessions were not documented on the record of service nor in the progress notes.
Patient #6 was admitted to the program on November 13, 2006. The patient had transferred from another methadone clinic where the patient was first admitted on June 26, 2006. The patient will not have 4 years in a methadone clinic until June 26, 2010. The patient is required to have at least 1 hour per month of group or individual psychotherapy. For the month of March 2010, the patient received .50 hours of psychotherapy. For the month of April 2010, the patient received .75 hours of psychotherapy. For the month of May 2010, the patient received .75 hours of psychotherapy.
An interview with the facility director on June 17, 2010 confirmed the patient records reviewed did not contain documentation that the patient had received the required psychotherapy hours.
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Plan of Correction
Program Director reviewed regulations with the staff at a staff meeting on June 28th. Program Director will review this standard in clinical supervision with all counseling staff. Chart monitoring of 12 random open charts will be done monthly by Program Director for continuous monitoring of this standard. |
715.20(4) 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.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on the review of patient records, the facility failed to document that it notified the referring facility of the admission and initial dosing of the patient in two of two patient records.
The findings include:
Twelve patient records were reviewed June 15-17, 2010. Two patient records were reviewed for documentation of notification to the referring facility of the admission and dosing of the referred patient. The facility did not document that the receiving narcotic treatment program notified the transferring narcotic treatment program, in writing, of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program in patient records # 3 and 5.
Patient # 3 transferred to the program and was admitted on March 3, 2010. There was no documentation in the patient record that the receiving narcotic treatment program notified the transferring narcotic treatment program, in writing, of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
Patient # 5 transferred to the program and was admitted on August 30, 2009. There was no documentation in the patient record that the receiving narcotic treatment program notified the transferring narcotic treatment program, in writing, of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
An interview with the facility director on June 17, 2010 confirmed the notifications were missing in the patient records reviewed.
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Plan of Correction
This standard was reviewed by the Director of Nursing. She then will retrain all nursing staff on proper procedure and importance of documentation by 7/31/10. Ongoing chart monitoring by the DON on a quarterly basis of 10% of charts will ensure ongoing compliance. |
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 the review of patient records, the facility failed to document an annual evaluation each patient's status completed by the patient 's counselor and reviewed, dated and signed by the medical director which included the patient's legal standing, financial management abilities and the patient's physical and emotional health in four of four patient records.
The findings include:
Twelve patient records were reviewed June 15-17, 2010. Four patient records were reviewed for compliance with the completion of the annual evaluation. The facility did not document a complete annual evaluation in patient records # 1, 2, 4 and 6.
Patient # 1 was admitted on 4/23/2009. The patient's annual evaluation, completed on April 23, 2010, did not address the patient's legal standing, financial management abilities and the patient's physical and emotional health.
Patient # 2 was admitted on February 27, 2009. The patient's annual evaluation, completed on February 24, 2010, did not address the patient's legal standing, financial management abilities and the patient's physical and emotional health.
Patient # 4 was admitted on July 10, 2006. The patient's annual evaluation, completed on July 10, 2009, did not address the patient's legal standing, financial management abilities and the patient's physical and emotional health.
Patient # 6 was admitted on November 13, 2006. The patient's annual evaluation, completed on November 13, 2009, did not address the patient's legal standing, financial management abilities and the patient's physical and emotional health.
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Plan of Correction
Form was reviewed by Director of OTP and Program Director. Form will be revised and implemented by 7/31/10. Program Director will monitor form for compliance as they are completed and given to PD for signature. |