INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection pertaining to the plans of correction for the September 8-10, 2010 methadone monitoring inspection. The follow-up inspection was conducted on April 12, 2011 by staff from the the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Rhd Montgomery County Methadone Center 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 during this inspection and a plan of correction is due on May 9, 2011.
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Plan of Correction
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715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
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Observations
Based on the review of patient record documentation, the facility failed to ensure the physician document in the patient record the rationale for granting take home medication in two of two patient records.
The findings include:
Seven patient records were reviewed on April 12, 2011. Two patient records were reviewed for take home medication documentation. Patient records # 1 and 2 did not have the physician's rationale for granting the take home medication.
Patient # 1 was admitted October 17, 2007. The patient was ordered to start receiving six take home bottles per week on December 10, 2010. The physician did not document a rationale for granting the six take home bottles.
Patient # 2 was admitted November 24, 1993. The patient was ordered to start receiving six take home bottles per week on November 24, 2010. The physician did not document a rationale for granting the six take home bottles.
The facility had documented this previously cited deficiency would be corrected by October 15, 2010.
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Plan of Correction
A meeting was held between the Program Director, Medical Director and PA-C to address the need for the Medical Director to document her justification for granting and rescinding client Taken Home Bottle Privileges. A written memo was also issued to the Medical Director by the Program Director documenting this requirement. Also, a new form was developed for this purpose to allow the Medical Director to complete this documentation. The Program Director will monitor the proper use of this form to insure that this deficiency does not occur again. Dtae of Completion: 5/4/2011 |
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 the review of patient records and discussion with administrative staff, the facility failed to transfer the required patient records in one of one patient record.
The findings include:
Three patient records were reviewed for transfer documentation. Only one of the three records was a transfer to another narcotic treatment facility. Patient record # 5 was transferred to another narcotic treatment facility March 17, 2011. There was no documentation of which specific records were transferred and the consent to release form signed by the patient restricted what files could be released to the receiving treatment program, limiting the release of the patient's file to those areas restricted under 4 PA Code 255.5, thereby not allowing for all of the required patient files to be transferred.
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Discussion with the program director and the clinical supervisor confirmed that the documentation was not in the patient record as required.
The facility had documented this previously cited deficiency would be corrected by September 23, 2010.
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Plan of Correction
An updated transfer release has been developed to allow patients to give consent to release all required transfer forms and not restricted to only the areas under 4 PA Code 255.5. a clincial meeting was held on 4/30/2011 to address the need for this requirement. Clinical Supervisor will monitor for compliance.Date of Completion: 4/30/2011 |
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 a review of patient records, the facility failed to document the behavioral steps for the patient to complete the established goals in two of three patient records reviewed.
The findings include:
Seven patient records were reviewed April 12, 2011. Three patient records were reviewed for treatment plan documentation.
Patient record # 1 did not have behavior tasks to perform to complete the short term goals. Instead, there were documented objectives to be met.
Patient # 2 had documented action steps that were not congruent to the short term goals listed.
The facility had documented this previously cited deficiency would be corrected by September 23, 2010.
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Plan of Correction
A clinical meeting was held by the clinical supervisor and the clinical staff to identify, distinguish the differences and the proper documentation of behavioral tasks, short term goals and objectives on client treatment plans. Clinical Supervisor will monitor all treatment plans for compliance. Date of Completion: 4/30/2011 |