INITIAL COMMENTS
|
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 April 7, 8 & 9, 2009 by staff from the Division of of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Foundations Medical Services, LLC was found not to be compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and a plan of correction is due on May 5, 2009.
|
Plan of Correction
|
715.6(a)(3)(i) 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.
(3) The medical director 's responsibilities include the following:
(i) Supervision of narcotic treatment physicians.
|
Observations
Based on the review of personnel records, facility policy and procedure and staff interviews, the facility failed to provide documentation that the medical director supervised other facility physicians.
The findings include:
Personnel records and facility policies and procedures were reviewed during the onsite monitoring. There was no documentation that addressed the medical director's responsibilities that included the supervision of facility physicians. Interviews with staff
confirmed there was no documented job description for the medical director that included duties to include supervision of other facility physicians.
|
Plan of Correction
The Program Director will update the Medical Director's responsibilities to include supervision of other narcotic treatment physicians. This will be completed and included in the Policy & Procedure manual by May 22, 2009.
A copy will be given to and signed by the Physician at Foundations Medical Services on May 23, 2009.
|
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.
|
Observations
Based on a review of 19 patient records, the facility failed to contact, with patient consent, the patients previous narcotic treatment facility for the treatment history in two of three patient records.
The findings include:
Nineteen patient records were reviewed April 7, 8 & 9, 2009. Three records were required to provide documentation that the facility attempted to contact previous narcotic treatment providers to secure patient treatment information. Patient records # 3 and 7 failed to contain documentation of attempts to gain previous treatment history. Staff interviews on April 9, 2009 confirmed that attempts had not been made to acquire previous treatment history for patients # 3 and 7.
|
Plan of Correction
The Program Director and Lead counselor will develop a template letter for counselors/staff to use when requesting treatment history from other narcotic treatment programs by May 1, 2009.
A procedure to request previous narcotic treatment information will be discussed with all clinical staff by May 1, 2009.
After May 1, 2009, each record, with consent from the patient, will contain a letter and/or phone call note requesting previous narcotic treatment information.
This item will be added (by May 30, 2009) to the chart monitor tool for internal auditing purposes.The Program Director and Lead Counselor will conduct chart monitoring, weekly, to see that the request for previous treatment records have been completed.
For new patients, this request for information will be conducted within the first month of treatment at Foundations Medical Center.
|
715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
|
Observations
Based on a review of patient records and staff interviews, the facility failed to maintain the confidentiality of their patients in two of nine patient records.
The findings include:
Nineteen patient records were reviewed on April 7, 8 & 9, 2009. The facility failed to maintain the confidentiality of two patients, # 18 and 19, as they exceeded the parameters of 4 Pa. Code 255.5. Patient # 18 signed a consent to release information that included the stipulation that urine drug screen results could be provided to a county agency. Patient # 19 signed a consent to release information that specified the information would be released to the patient for purposes of providing information such as urine drug screens to other organizations and individuals. Staff interviews conducted during the on site inspection confirmed that the identified releases exceeded the information that is allowed by regulation.
|
Plan of Correction
The Program Director (a BDAP trainer for Confidentiality) will facilitate a training at Foundations specific to reviewing and updating the parameters of 4 Pa. Code 255.5 by May 30, 2009.
Releases will be reviewed for accuracy when chart monitoring is conducted (5 charts per week or more as needed) by Program Director and Lead Counselor.
|
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.
|
Observations
Based on a review of patient records and staff interviews, the facility failed to limit involuntary terminations to those reasons identified in the regulations in 2 of 3 patient records.
The findings include:
Nineteen patient records were reviewed April 7, 8 & 9, 2009. Three records were required to contain documentation pertaining to involuntary terminations of patients. Patient # 9 was discharged March 17, 2009 for refusing to enter a higher level of care following drug screen tests that identified the patient's use of illicit substances. The patient had been a March 5, 2009 admission; there was no documentation that specified treatment interventions to assist this patient. Patient # 11 was discharged on December 9, 2008 for the failure to follow treatment rules and a behavior contract. A review of the patient record revealed the patient did not have a treatment plan that specifically addressed the illicit drug use issues the patient had while in treatment. Staff interviews addressed the reasons for the patient terminations in patient # 9 and 11 and confirmed the reasons for the involuntary terminations exceeded those
identified in the regulations.
|
Plan of Correction
Program Director, Lead Counselor will review with all staff the "involuntary termination" definition per DOH regulations by May 15, 2009.
Policies and procedures will be reviewed and updated by the Program Director to reflect the regulations and outline the procedure that a patent's case being found to meet the regulatory definition must be reviewed and approved by the Program and Medical Director prior to taking action. This update and review will happen by May 15, 2009.
Treatment planning training will be facilitated by Foundations Program Director on May 13, 2009. Treatment plans will be reviewed upon their completion by the Program Director and Lead Counselor for specifics that address the patient's problem areas including continued illicit drug use and difficulties with following treatment goals and rules.
|
715.21(2) 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.
(2) A patient terminated involuntarily, except a patient who commits or threatens to commit acts of physical violence, shall be afforded the opportunity to receive detoxification of at least 7 days. The detoxification may take place at the facility or the patient may be referred to another narcotic treatment program or hospital licensed and approved by the Department for detoxification.
|
Observations
Based on a review of patient records and staff interviews, the facility failed to provide termination letters to patients that they had involuntarily terminated in three of three patient records.
the findings include:
Nineteen records were reviewed on April 7, 8 and 9, 2009. Three patient records were required to include documentation of a termination letter in three records. The facility failed to document that letters of termination were provided to patients 8, 11 and 12. A review with staff revealed letters of termination had not been provided to these patients.
|
Plan of Correction
A template termination letter will be reviewed with the staff by the Program Director by May 31, 2009. All Involuntary Terminated patients will receive a copy of this letter 48 hours prior to being terminated.
Involuntary terminations will be discussed and reviewed by the team in case conference weekly. Records will be reviewed by Program Director and Lead Counselor within one week of termination for completion of all documentation including a copy of the letter given to patients.
|
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.
|
Observations
Based on review of nineteen patient records, the facility failed to ensure that all annual evaluations were completed as required in one of four records.
The findings include:
Nineteen patient records were reviewed on April 7, 8 and 9, 2009. Four records were reviewed for annual evaluation content. Patient record # 6 was missing an annual evaluation for 2008. Staff interview revealed that patient # 6 had not had an annual evaluation performed in 2008.
|
Plan of Correction
The Program Director and Lead Counselor will review the specifics needed in annual evaluations with counselors by May 15, 2009.
Chart monitors (x5 weekly) will be conducted by the same staff identified above for completion of annual reviews.
|
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.
|
Observations
Based on the review of patient records, the narcotic treatment program failed to document treatment plans in four of nine patient records.
The findings include:
Nineteen patient records were reviewed on April 7, 8 and 9, 2009. Comprehensive treatment plans were required in nine patient records. The narcotic treatment program did not document individualized short and long term goals in the treatment plan in patient records # 3, 4, 6 and 7.
|
Plan of Correction
The Program Director will facilitate a 3-hour treatment planning training for all clinical staff on May 13, 2009. This training will offer an overview and practical application of writing problem statements, short- and long ?term goals related to the patient's assessment information.
Treatment plans will be reviewed, monitored, and signed off by the Lead Counselor and Program Director after they are completed (on time per regulations) and include realistic short and long-term goals relative to and agreed upon by the patient.
|