INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use narcotic agents, specifically methadone and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on December 6-8, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Directions Treatment Services, 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 January 1, 2011.
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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 the review of patient records, the facility failed to contact the previous facility for the patient's treatment history in three of three patient records reviewed.The findings include:Thirty-three patient records were reviewed December 6-8, 2010. Three patient records required contacting the prior treatment facility for the treatment history. Patient records # 3, 26, and 29 did not have documentation of any attempt to obtain the patient's prior treatment history from prior treatment facilities.
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Plan of Correction
All staff members who conduct intakes have been advised of the necessity of requesting documentation of prior treatment at an NTP for all incoming patients. If such treatment has occurred, as is almost invariably the case, the person conducting the intake, with patient consent, will send a request for information to the treatment facility to verify the prior treatment history. As these requests are frequently not honored, staff has been instructed to save a copy of the letter requesting such documentation in the chart in case no records are obtained. A member of the clerical staff will be assigned the task of reviewing documentation of all admissions for the inclusion of said records, or requests for them and will verify to the Program Director that this task has been completed and whether or not the necessary documentation is included in the chart. The Program Director will assume responsibility for ensuring that this corrective action is implemented and will monitor in the manner already described to ensure ongoing compliance. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on the review of the facility policy and procedure manual and staff interview the facility failed to update the onsite photographs of the clients every three years. The findings include:The facility policy and procedure manual was reviewed on December 6, 2010. According to the policy and procedure manual the facility shall update the onsite photograph of the client every three years. An interview with the facility director on December 8, 2010 at 10:20 a.m. confirmed that the photographs of the patients that have been in treatment for three years have not be updated.
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Plan of Correction
All patients who have been in continuous treatment at New Directions for 3 years or longer have been identified. A list of their names has been generated and the nursing staff will be taking new photographs of each of them during the month of January 2011. The Intake Coordinator will be downloading all of the photos and verifying that they get matched to the correct patient. A new report has been created that will identify patients who during the upcoming month will cross the 3-year continuous treatment threshold. The Nursing Supervisor will generate this report at the beginning of each month and distribute it to the nursing staff with instructions for each of these patients to have their photos reshot during that month. She will confirm to the Program Director that all the photos have been taken and downloaded into the system. Currently all incoming patients have their photos taken at the time of admission. All patient photos in the future, including the backlog that is to be reshot in January will be date stamped on the photo for easy verification. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on the review of patient records, the facility failed to ensure at least monthly random urine drug-screens for five of twenty-four patient records.The findings include:Thirty-three patient records were reviewed December 6-8, 2010. Twenty-four patient records were reviewed for monthly urine drug screen results. Five patient records did not include the required documentation of monthly urine drug-screens. Patient record # 2 was missing a urine drug screen for September 2010. Patient record # 7 was missing a urine drug screen for August 2010.Patient record # 10 was missing a urine drug screen for June 2010.Patient record # 17 was missing a urine drug screen for July 2010.Patient record # 33 was missing a urine drug screen for November 2010.
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Plan of Correction
The list that is used to identify patients who are due to be tested has been revised to schedule testing at a maximum of three weeks from the last test for each patient. Previously, long term stable patients were scheduled at four week intervals such that any failure to collect a specimen on time would potentially result in noncompliance with this standard. It is expected that this change will prevent this problem occurring in the future. However, as an additional precaution the Program Director will run a report monthly that will list the two most recent collection dates for all patients where the collection dates are more than 30 days apart. Full compliance would be indicated by no one appearing on the report. If anyone does, the Program Director will follow up to ascertain the reason and take whatever remedial action is required. |
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 a review of patient records and an interview with the facility director, ten were required to have documentation of the narcotic treatment physician's rationale for permitting take-home medication. The narcotic treatment program failed to document the narcotic treatment physician's rationale in ten of ten records.Findings:Thirty-three patient records were reviewed on December 6-8, 2010. The narcotic treatment physician failed to document the rationale for permitting take-home medication in patient records # 2, 4, 12, 13, 14, 15, 21, 27, and 28. An interview with the facility director on December 8, 2010 at 12:50 p.m. confirmed that the narcotic treatment physician was not documenting the rationale in the patient record; however, take-home rationale was being discussed in treatment team meetings. Record #2 was missing the required documentation of the narcotic treatment physician's rationale.Record #4 was missing the required documentation of the narcotic treatment physician's rationale.Record #12 was missing the required documentation of the narcotic treatment physician's rationale.Record #13 was missing the required documentation of the narcotic treatment physician's rationale.Record #14 was missing the required documentation of the narcotic treatment physician's rationale.Record #15 was missing the required documentation of the narcotic treatment physician's rationale.Record #21 was missing the required documentation of the narcotic treatment physician's rationale.Record #24 was missing the required documentation of the narcotic treatment physician's rationale.Record #27 was missing the required documentation of the narcotic treatment physician's rationale.Record #28 was missing the required documentation of the narcotic treatment physician's rationale.
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Plan of Correction
The electronic documentation of medication orders that change patient take-home schedules was not properly provisioned to generate this information as part of the order. That part of the order generation process has been modified to capture this information going forward. This solution is already in use and has been verified as being used consistently by the Program Director who will also monitor on an ongoing basis to insure that it continues to be used. A report has been developed that will be run on a monthly basis by the Program Director, or his designee, that will identify any instances of schedule change orders that do not have a rationale for the change included as part of the order.
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715.16(f) LICENSURE Take-home priveleges
(f) An exception granted under subsection (d) shall continue only for as long as the temporary disability or exceptional circumstance exists. When a patient is permanently disabled, that case shall be reviewed at least annually to determine whether the need for the exception still exists.
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Observations
Based on the review of patient records, a review of administrative documentation, and an interview with the facility director, the facility failed to review annually to determine whether the need for the exception for 13 day take-home still existed.The findings include:Thirty-three records were reviewed on December 6-8, 2010. The Methadone Monitoring Questionnaire documented that the twenty-six patients at the facility had 13-day take home privileges due to permanent physical disability. Eight records were reviewed for documentation that the 13-day take home privilege still existed annually. Five of eight records failed to include documentation that the justification for 13-day take homes still existed in client records # 17, 27, 28, 30, and 32. An interview with the facility director confirmed that the documentation for annual review was not being completed.
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Plan of Correction
The patients who have been granted 13-day take-home privileges more than one year ago have been identified and are scheduled to be reviewed in January 2011 if they did not already have a scheduled date that would keep them in compliance with this standard. All patients who have been approved for 13-day take-home privileges due to permanent disability will be reviewed during the month of January in the future. They will be identified by the Nursing Supervisor from a report that is run at the beginning of the new year. They will be presented to the Program Physician by the counselor and Nursing Supervisor with an update of the patient's current status for the physician's consideration. The Program Director will verify that all persons whose dosing schedules are currently determined by this exception have been reviewed. The physician will document the review in the patient's chart as a medication order which, when it applies, explicitly states that the patient's need for the exception continues to exist. Each January all such exceptions, regardless of when they have been granted, will be reviewed as described, and the Program Director will verify that the orders have been generated with a statement that explicitly attests to the continued need.
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715.17(b) LICENSURE Medication control
(b) A narcotic treatment program shall develop policies and procedures regarding verbal medication orders, including the issuing and receiving of orders, identifying circumstances when orders are appropriate and documenting orders, in accordance with applicable Federal and State statutes and regulations.
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Observations
Based on the review of patient records, the facility failed to ensure the physician signed and dated the verbal order within 24 hours as required by regulation in two of two patient records reviewed. The findings include:Thirty-three patient records were reviewed December 6-8, 2010. Two records contained documentation of a physician's verbal orders. While the physician did sign these verbal orders, the signature was not dated within 24-hours as required by our regulation in patient records # 5 and 21.Patient record # 5 had a verbal order written by a nurse on 9/2/2010 and it was not signed and dated by the doctor until 9/7/2010.Patient record # 21 had a verbal order for a dose change written by a nurse on 11/10/10 and it was not signed and dated by the doctor until 11/12/2010.This is a repeat citation from the methadone monitoring visit conducted on May 24-26, 2010.
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Plan of Correction
The Program Physician will generate a report daily that lists all of the unsigned verbal orders and sign them. The Program Director will run another report on a weekly basis that lists all orders, signed or unsigned from the prior week. This report, employing a user-defined date range, lists the status (signed/unsigned) of all the orders and the number of days between the date written and the date signed for all verbal orders. The Program Director will follow up with the Program Physician if there are any instances of unsigned orders or verbal orders signed more than 24 hours after being written. |
715.23(d) 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.
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Observations
Based on the review of patient records, the facility failed to document treatment plan updates with realistic short and long term goals with action steps that are congruent with the goals in three of eighteen patient records. Additionally, the facility failed to have current treatment plan updates in four of eighteen patient records. The findings include:Thirty-three patient records were reviewed December 6-8, 2010. Eighteen patient records were reviewed for treatment plan update documentation compliance. Patient records # 25, 27 and 30 contained behavioral steps for the patients to complete that were incongruent with the stated goals. Patient record # 9 failed to have a current treatment plan update. The last treatment plan update was dated 4/23/2010. As of the date of the inspection the treatment plan update had not been updated per licensing regulation of every sixty days. Patient record # 14 was admitted on 3/22/2010 and the record failed to have a current treatment plan update. Patient record # 31 had the same treatment plan update duplicated since October 13, 2007. The facility failed to make any changes and update the treatment plan with realistic short and long term goals in the past three years. Patient record # 33 last treatment plan update was dated 9/24/2010. As of the date of the inspection the treatment plan update had not been updated per licensing regulation of every sixty days.
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Plan of Correction
The Clinical Supervisor conducted an in-service training with the counseling staff today, 1/25/2011. Specifically addressed in that training were all of the issues identified in the citation: congruence, timeliness and redundancy. The Clinical Supervisor and Assistant Clinical Supervisor, both of whom currently review a sampling of clinical charts monthly for a variety of documentation issues, will intensify this activity, that is, increase the sample size for review and focus more attention on both the quality and timeliness of treatment plan updates. Counselors who exhibit deficiencies in these areas will receive additional individual attention focusing on treatment plan update activities in their weekly clinical supervision sessions. The Clinical Supervisor and Assistant Clinical Supervisor will be responsible to monitor counselor performance in this area and report any continued problems to the Program Director. |
715.29(5) LICENSURE Exceptions
A narcotic treatment program is permitted, at the time of application or any time thereafter, to request an exception from a specific regulation.
(5) If the exception relates to a specific patient, the narcotic treatment program shall maintain documentation of the exception in the patient 's record.
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Observations
Based on a review of patient records and an interview with the nursing supervisor, the facility failed to document all components required for an exception in five of five patient records.The findings include:Thirty-three patient records were reviewed on December 6-8, 2010. Thirteen patient records were required to have documentation pertaining to a previously approved exception. The facility failed to comply with the conditions of the exception granted by the Division regarding thirteen day take-home privileges. Patients on a thirteen day status must have quarterly call backs (an unscheduled return to the facility within 24 hours) that included an inventory of the patient's remaining take home supply, a documented review of the patient's status, and drug testing or methadone plasma levels. The facility failed to conduct quarterly call backs with drug testing for patients # 17, 25, 27, 30, and 32. Patient # 17 was admitted into treatment on January 21, 2003. The facility received a Department approved exception for this patient to receive a thirteen day take-home status. There was no documentation of call backs with drug testing in the patient record.Patient #25 was admitted into treatment on April 2, 2007. The counselor noted in a progress note on August 25, 2010 the patient had received approval by the physician for 13 take home bottles. The counselor also noted in the treatment plan update review on September 22, 2010 that patient recently received 14 take outs. Also, the counselor noted on a treatment plan update review on November 17, 2010 the patient abided by the conditions of the 13 take home approval requirements. There was no documentation of call backs with drug testing documented in the patient record.Patient # 27 was admitted into treatment on April 6, 2005. The facility received a Department approved exception for this patient to receive a thirteen day take-home status. There was no documentation of call backs with drug testing documented in the patient record.Patient # 30 was admitted into treatment on May 17, 1997. The facility submitted a Department approved exception for this patient to receive a thirteen day take-home status. There was documentation of call backs and review of the patient's status on 5/27/2010 and 8/10/2010. There was only documentation of two call backs in one year as of the date of the inspection. Patient # 32 was admitted into treatment on August 31, 1992. The patient receives a thirteen day take-home status. There was no documentation of call backs with drug testing documented in this patient's record since 2/14/2008.
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Plan of Correction
All patients approved for 13 take-home privileges will have the documented approval of this exception inserted into their chart. The patient will also sign a statement indicating that they understand the requirements of maintaining the approval, e.g. reliable availability by phone, quarterly callbacks, annual review of disability status, absence of drug use, etc. The Clinical Supervisor will verify the inclusion of these documents in the chart. A report will be developed that will identify all patients who have been approved for 13 take-home privileges and who are due in the current month for a callback. A member of our clerical staff will manage this process and report to the Program Director. She will contact the patient and schedule him/her to come in the next day for a drug screen and bottle inventory. She will post a message on the patient's dispensing screen to alert the dispensing staff to expect the patient. Members of the dispensing staff will be instructed to document when the patient comes in, that a proper account was made/not made of the bottles and that a specimen was collected for testing. The clerical person managing this process will verify the following day whether or not the patient met the requirement. Patients failing to meet the requirement will lose 13 take-home privileges. The manager of this process will notify the patients' counselors regarding all callbacks due during the month, post notes to the patients' charts indicating the callback outcomes and submit a report at the end of the month to the Program Director specifying the callback outcomes for the month.
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