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 September 23,24 & 24, 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 October 28, 2008.
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Plan of Correction
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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 a review of 30 patients on September 24 and 25, 2008, 6 were reviewed for compliance with the standards to obtain information from prior treatment experiences. The facility failed to provide documentation that they had contacted patients' prior treatment programs to request treatment information in 2 of 6 patient records where required.
Findings:
Documentation in patient records # 21 and 28 revealed that these patients had reported previous narcotic treatment experiences. There was no documentation in either of these two patient records that the previous treatment providers had been contacted for information.
This is a repeat citation.
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Plan of Correction
Utilization review coordinator will inform program director of all new clients admitted with previous treatment experience and of all clients re-admitted into the program. Program director will follow-up with counselor on attempts at obtaining previous treatment records and/or documentation of prior treatment records if client is being re-admitted. Also, the new chart monitor tracking log will record if client is a transfer or re-admit and the date the client's previous treatment records have been requested and the date they were received. This will alert the program director of the need for continued follow-up if the records have not been received.
Counselors have been instructed to identify previous treatment records on clients who are readmitted into the program.
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715.16(c)(3)(i-viii) 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:
(3) A narcotic treatment program may permit a patient to reduce attendance at the narcotic treatment program for observation to one time weekly and receive no more than a 6-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 years.
(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.
(v) A patient demonstrates no major behavioral problems.
(vi) A patient is employed, is actively seeking employment, attends school, is a homemaker or is considered unemployable for mental or physical reasons.
(vii) A patient is not known to have abused alcohol or other drugs within the previous year.
(viii) A patient is not known to have engaged in any criminal activity within the previous year.
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Observations
Based on a review of 30 patient records on September 24 and 25, 2008, one patient record was reviewed for compliance with a 6 day take-home schedule. The facility failed to document rationale for continued take-home privileges for patient #20 following a urinalysis drug test that indicated illicit drug use.
Findings:
Patient record # 20 revealed documentation of random urinalysis drug screen that identified use of an illicit substance. There was no documentation in the patient record that addressed this issue. Further, review of the patient record revealed the patient continued to receive 6 day take-home privileges.
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Plan of Correction
Counselor failed to document that client's positive urine screen was the result of a prescribed medication to be taken as needed. Counselor also failed to document that the client continues to remain stable and therefore; take-home privileges were not rescinded.
Counselors have been instructed to thoroughly document justification for continued take-home privileges when a client's privileges may otherwise have been rescinded.
Program director will follow-up with counselor to ensure that thorough documentation has been added to client's clinical chart if client is granted continued take-home privileges when privileges may otherwise have been rescinded. Nursing will also add documentation to client's medical chart.
To begin immediately.
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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 30 patient records on September 24 and 25, 2008, 21 patient records were reviewed for compliance with the requirements for the provision of psychotherapy services. The facility failed to provide each patient with the minimal requirement of an average of 2.5 hours of psychotherapy per month during the patient's first two years of treatment. Psychotherapy was not provided as required in 11 of 21 patient records.
Findings:
Patient # 1 received 1.0 hour of psychotherapy in August 2008, 30 minutes in July 2008 and 30 minutes in June 2008 for an average of .67 hours of psychotherapy per month.
Patient # 2 received 2.5 hours of psychotherapy in August 2008, 0 hours in July and June 2008 for an average of .83 hours of psychotherapy per month.
Patient # 3 received 3.75 hours of psychotherapy in August 2008, 0 hours in July and June 2008 for an average of 1.25 hours of psychotherapy per month.
Patient # 4 received 0 hours of psychotherapy in August 2008, 1.25 hours in both July and June 2008 for an average of .83 hours of psychotherapy per month.
Patient # 9 received 0 hours of psychotherapy in August 2008, 45 minutes in July and 0 hours in June 2008 for an average of 15 minutes of psychotherapy per month.
Patient # 10 received 0 hours of psychotherapy in August 2008, 0 hours in July 2008 and 1.25 hours in June 2008 for an average of .42 hours of psychotherapy per month.
Patient # 17 had 0 hours of psychotherapy recorded for the past 3 months.
Patient # 18 received 0 hours of psychotherapy in August 2008, 0 hours in July 2008 and 1.25 hours in June 2008 for an average of .42 hours of psychotherapy per month.
Patient # 19 received 30 minutes of psychotherapy in August 2008, 30 minutes in July 2008 and 30 minutes in June 2008 for an average of 30 minutes of psychotherapy per month.
Patient # 21 received 2.75 hours of psychotherapy hours in August 2008, 1.25 hours in July 2008 and 2.75 hours in June 2008 for an average of 2.25 hours of psychotherapy per month.
Patient # 26 received 1.25 hours of psychotherapy hours in August 2008, 2.5 hours in July 2008 and 2.5 hours in June 2008 for an average of 2.0 hours of psychotherapy per month.
This is a repeat citation.
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Plan of Correction
Counselors who have tended to be lenient with clients missing scheduled functions have been instructed to be more adamant with client's attendance and increase consistency with expectations regarding attendance.
Counselors have also been counseled on implementing treatment plans regarding lack of attendance and to increase documentation of clients who are not attending scheduled functions. Rescinding of take-home privileges of those clients who consistently cancel scheduled functions has increased. To begin immediately.
Program director will continue monitoring client hours weekly by utilizing client hours log and address with counselor any areas of non-compliance with recommended treatment. Program director will also monitor client chart's for documentation of non-compliance and attempts at enaging client in treatment. To begin immediately.
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715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of 30 patient records on September 24 and 25, 2008, 2 patient records were reviewed for compliance with the standards regarding transfers to other methadone treatment facilities. The facility failed to provide documentation of patient consent in 1 of 2 patient records where required.
Findings:
Patient record # 17 contained documentation that the patient had been transferred, however there was no documentation of written consent by the patient that was required prior to the facility's initiation of the transfer.
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Plan of Correction
Client #17
The nurse obtained consent from client and submitted to counselor. Counselor did not file consent in chart. This counselor has been given disciplinary action regarding this issue.
Staff has been counseled on the importance of filing documentation in the chart in a timely manner.
Program director will increase vigilance when performing monthly chart reviews. Staff has also been informed to increase their awareness of missing documentation when performing weekly peer chart reviews. To begin immediately.
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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 30 patient records on September 24 and 25, 2008, 21 were reviewed for counselor note content. The facility failed to document patient progress and status in 9 of 21 patient records reviewed.
Findings:
Patient record # 6 had no clinical documentation of patient contact since 7/18/09. Additionally, the progress note for the 7/18 entry was written a month after the contact, on 8/19/08.
Patient record # 20 contained no counselor notes since 5/5/08.
Patient records # 7, 8, 21, 23, 24, 26 contained photocopied group notes that did not specifically assess the patient's participation and ongoing treatment needs. Identical group
notes were included in numerous patient records.
This is a repeat citation.
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Plan of Correction
Client #6
We are aware of this deficiency. This citation is the result of the unsatisfactory performance of one particular counselor. We instituted disciplinary action with this counselor which over time resulted in termination. Unfortunately, during this disciplinary period some charting requirements were not completed. Counselor was terminated on 9-23-08.
Client #20
Refer to client #6. Counselor was terminated on 9-23-08
Client # 7, 8, 21, 23, 24, 26
Refer to client #6. Counselor was terminated on 9-23-08
Program director will increase vigilance when performing monthly chart reviews. Staff has also been informed to increase their awareness of missing documentation when performing weekly peer chart reviews. To begin immediately.
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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 a review of facility policy and procedure and 30 patient records from September 23 through 25, 2008, 4 patient records were reviewed for psychosocial content. The facility failed to document complete and timely psychosocial evaluations in 2 of 4 patient records where required.
Findings:
Patient # 2 entered into treatment on 3/31/08; her psychosocial evaluation was not completed until 6/2/08. It is the facility's policy that the psychosocial evaluations will be completed within one month of admission.
Patient record # 4 did not include the clinical assessment that was a required component in all psychosocial evaluations.
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Plan of Correction
A chart monitor tracking log was implemented on 10-6-2008. The counselor enters the admit date and this tool automatically generates the due date for the psychosocial, treatment plan updates, case consults, and annual reviews/physicals. Upon completion of entering the data the counselor submits the chart to the program director who utilizes this chart on a weekly basis to monitor what is due. The program director then request to review the documentation with the counselor to ensure it has been completed and completed within the appropriate time frame.
Program director is responsible for monitoring to ensure that chart documentation has increased and that documentation is thorough and complete through weekly chart monitoring.
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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 30 patient records on September 24 and 25, 2008, 3 were reviewed for aftercare content. In 2 of 3 patient records, the facility failed to document the specific needs of the patient in the aftercare plan.
Findings:
Patient record # 11 contained an aftercare plan that did not include recommendations and referrals specific to her ongoing treatment needs.
Patient record #12 contained no documentation of an aftercare plan; documentation specified no aftercare was needed because the patient would be treated by her primary care physician. There was no aftercare plan to address the clinical needs of the patient.
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Plan of Correction
Plan of Correction:
Clinicians have been counseled on the importance of completing aftercare for all discharging clients. Staff completed a training on 10-29-08
that addressed the need to individualize recommendations, referrals and goals based on the clients ongoing treatment needs. Program director will be made aware of client's upcoming discharge as soon as possible. To prevent further problems, the program director will monitor aftercare plans by reviewing with counselor client's aftercare plans to ensure that it has been completed thoroughly and appropriately. To begin immediately.
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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 30 patient records on September 24 and 25, 2008, 9 patient records were reviewed for compliance with follow-up services following the patient's discharge. The facility failed to document follow-up services in accordance with the facility's policy and procedure on follow up in 5 of 9 patient records where required.
Findings:
Following their discharge, there was no documentation of follow-up attempts for patients # 9, 10, 11, 13 and 15.
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Plan of Correction
Clients # 9, 10, 11, 13 and 15.
The policy is being followed and follow-up contacts are being made but documentation of this follow up is not complete.
Counselors have been instructed to document all follow-up attempts upon client's discharge.
A chart monitor tracking log was implemented on 10-6-2008. The counselor enters the admit date and this tool automatically generates the due date for the psychosocial, treatment plan updates, case consults, and annual reviews/physicals. Clients discharge date and all follow-up attempts are being tracked on this log as well. Upon completion of entering the data the counselor submits the chart to the program director who utilizes this chart on a weekly basis to monitor what is due. The program director then request to review the documentation with the counselor to ensure it has been completed and completed within the appropriate time frame.
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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 30 patient records on September 24 and 25, 2008, 6 patient records were reviewed for compliance. The facility failed to meet the criteria required for compliance in 6 of 6 patient records reviewed.
Findings:
Patient record # 1 contained an annual evaluation that that did not include an assessment of patient status. Additionally, the evaluation was not signed and dated by the medical director.
Patient record # 3 did not contain documentation of an evaluation that was due August 2008.
Patient record # 5 did not contain documentation of an evaluation that was due August 2008
Patient record # 7 contained an annual evaluation that that did not include an assessment of patient status. Additionally, the evaluation was not signed and dated by the medical director.
Patient record # 8 contained a patient evaluation that was not signed and dated by the medical director.
Patient record # 22 did not contain documentation of an evaluation that was due May 2008.
This is a repeat citation.
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Plan of Correction
A training on the completion of the annual review is scheduled for 10-29-08. Counselors will be instructed to include a brief update of the clients previous year in treatment and an evaluation of the client's needs.
A chart monitor tracking log was implemented on 10-6-2008. The counselor enters the admit date and this tool automatically generates the due date for the psychosocial, treatment plan updates, case consults, and annual reviews/physicals. Upon completion of entering the data the counselor submits the chart to the program director who utilizes this chart on a weekly basis to monitor what is due. The program director then request to review the documentation with the counselor to ensure that all signatures have been obtained and the forms have been completed within the appropriate time frame.
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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 30 patient records on September 24 and 25, 2008, 13 were reviewed for treatment plan content. The facility failed to develop treatment plans that contained short term goals with measurable steps in 7 of 13 patient records reviewed. The facility failed to document identified support services in 7 of 13 patient records.
Findings:
Patient records # 1, 2, 3, 4, 5, 7 and 22 failed to include specific and measurable action steps in the treatment plans. Additionally, there were no support services documented in the treatment plans for patients # 1, 2, 3, 4, 5, 7, and 22.
This is a repeat citation.
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Plan of Correction
Clients # 1, 2, 3, 4, 5, 7, and 22.
The new treatment plans listing support services were implemented later than expected. This has since been corrected as the new treatment plans were implemented at the beginning of September and all counselors have been instructed to utilize the new form when the client's treatment plan update is due.
Counselors have been retrained on the development of treatment plans to include short term goals and documentation of identified supports. A follow-up training is scheduled for 10-16-08.
This will be monitored by the program director upon review and signing of the treatment plans. To begin immediately.
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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 30 patient records on September 24 and 25, 2008, 13 were reviewed for compliance regarding treatment plan updates. Five of 13 patient records failed to provide documentation of treatment plan updates and modifications.
Findings:
Patient records # 1, 2, 3 and 7 contained treatment plans that failed to identify patient progress and reevaluation of patient goals. The documentation in these records did not address the specific efforts made by the patient to complete the goals in their treatment plans.
Patient record # 5 contained no documentation of treatment plan updates between 1/28/08 and 6/5/08.
This is a repeat citation.
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Plan of Correction
Counselors will be retrained on the development of treatment plans and documentation of client progress or lack of on10-29-08.
Program director will increase vigilance when performing monthly chart reviews and will more thoroughly monitor documentation content. Program director will also increase thoroughness when reviewing treatment plans and treatment plan updates prior to signing. Staff has also been informed to increase their awareness of missing documentation when performing weekly peer chart reviews. To begin immediately.
Program director will increase vigilance when performing monthly chart reviews. Staff has also been informed to increase their awareness of missing documentation when performing weekly peer chart reviews. To begin immediately.
A chart monitor tracking log was implemented on 10-6-2008. The counselor enters the admit date and this tool automatically generates the due date for the psychosocial, treatment plan updates, case consults, and annual reviews/physicals. Upon completion of entering the data the counselor submits the chart to the program director who utilizes this chart on a weekly basis to monitor what is due. The program director then request to review the documentation with the counselor to ensure it has been completed and completed within the appropriate time frame.
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