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 provision of outpatient maintenance treatment for opioid dependence. This inspection was conducted on December 1-3, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, SOAR, Inc. 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 January 1, 2009. .
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Plan of Correction
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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the narcotic treatment program failed to have a narcotic treatment physician make a face-to face determination and document in the patient's record a current and 1 year history of addiction prior to admission for maintenance treatment in one of three patient records.
Findings:
Nine patient records were reviewed on December 1-3, 2008. Three were reviewed for documentation of current and 1 year history of addiction prior to admission. Patient # 5 was admitted on 9-25-08 and received the first dose on 9-26-08, but the documentation of addiction was not completed until 10-3-08.
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Plan of Correction
An in-service will be provided by the Director for the Program Physician regarding documentation of current and 1 year history of addiction prior to admission for maintenance treatment. The Program Physician will ensure that proper documentation is completed on all new admissions and ongoing. The Clinical Supervisor will monitor for compliance with completion of record reviews. |
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 patient records, the narcotic treatment program failed to contact prior narcotic treatment facilities for the patient's treatment history in one of one patient records.
Findings include:
Nine records were reviewed on December 1-3, 2008. Four records were reviewed for prior treatment history and one of the four contained documentation of prior narcotic treatment history at other facilities. Record # 5 did not contain documentation of contact with the previous treatment facilities.
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Plan of Correction
An in-service training will be provided to the clinical staff on Contacting the patients previous Narcotic Treatment Provider by Patient Consent on all patients that report a past MMT experience. The Director will ensure that the training is completed. The Clinical Supervisor will monitor documentation for ongoing compliance. |
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).
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Observations
Based on a review of patient records, the facility failed to secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 and 709.28.
Findings include:
Nine records were reviewed on December 1-3, 2008. Nine records were required to maintain patient confidentiality. Five records were reviewed for the content of the written consent to release information. Three of five records did not have consents to release information that included the name of the person to whom the information was being released, the specific information to be released and/or the purpose for the release of information. Record # 1 contained a signed blank consent to release information. Records # 5 and 9 were missing the purpose for the release of the information. In addition two other records (# 2 and 3) contained identifying information of other patients.
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Plan of Correction
An In-Service training will be provided by the Director for all Clinical Staff regarding the consents to release information that included the name of the person to whom the information was being released, the specific information to be released and/or the purpose for the release of information. The Clinical Supervisor will monitor for ongoing compliance. |
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 a review of patient records, the narcotic treatment program failed to ensure random monthly urinalysis for three of eight patients reviewed.
Findings include:
Nine patient records were reviewed on December 1-3, 2008. Eight were reviewed for initial and monthly drug-screening urinalysis. Three records were missing at least one required monthly urinalysis. Record # 1 was missing a urinalysis for September 2008. Record # 4 was missing a urinalysis for October & November 2008. Record # 6 was missing a urinalysis for November 2008.
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Plan of Correction
The Director will ensure that the nurse manager is properly educated on monitoring complaince with monthly urinalysis. The nurse manager will monitor complaince of monthly urinalysis for ongoing complaince. |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on a review of patient records, the narcotic treatment program failed to ensure the physician completed the dose reviews to determine patient's therapeutic dosage in two of three records.
Findings include:
Nine patient records were reviewed on December 1-3, 2008. Three records were reviewed for dose review documentation. In records # 8 and 9, the dose review was completed by the Certified Registered Nurse Practitioner (CRNP) and not by the physician as required.
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Plan of Correction
An in-service will be provided by the Director for the Medical staff regarding DAPL policies for Dose
Review(s). The Director will issue a memo and follow up for complaince. Dose Reviews will be monitored by the Director/and Clinical Supervisor for ongoing compliance. |
715.21 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.
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Observations
Based on the review of patient records, the facility failed to restrict the reasons for involuntary termination to those addressed in the regulations.
Findings include:
Nine records were reviewed on December 1-3, 2008. Three records, # 1, 2 and 3, were reviewed for involuntary termination. The patients reviewed contained a form that listed loitering and falsification of urine drug screens as reasons for discharge.
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Plan of Correction
The Director will add a revision to the current Involuntary Termination Notice for removal of loitering and falsification of urine drug screens as reasons for discharge. The Director will issue all clinical staff revision of form. |