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 November 2 through November 4, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Soar Corp. 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 a plan of correction is due on December 01, 2010.
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Plan of Correction
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of administrative documentation and staff interviews, the facility failed to provide at least one hour of physician time a week, on site for, every ten patients.The findings include:Physician time sheets and and census reports for the months of June, July, August, September and October were reviewed on November 3, 2010. There were insufficient onsite physician hours during June, July and September. During the week of June 28 through July 3, 2010, the census was 216 patients. There were 25 provided hours by the Certified Registered Nurser Practitioner. One third of those hours needed to be provided by the physician. There were 0 physician hours documented for this time period. During the week of July 4-11, 2010, the census was 216 patients. There were 25 provided hours by the Certified Registered Nurser Practitioner. One third of the required hours were to be provided by the physician. There were 0 physician hours documented for this time period. During the week of August 1-7, 2010, the census was 216 patients. There were 31.75 hours provided by the Certified Registered Nurse Practitioner. One third of the required hours were to be provided by the physician and there were only 6 physician hours documented..During the week of August 15-21, 2010, the census was 216 patients. There were 32 hours provided by the Certified Registered Nurse Practitioner. One third of the required hours were to be provided by the physician and there were only 6.5 physician hours documented.During the week of August 29 through September 4, 2010, the census was 216 patients. There were 32 hours provided by the Certified Registered Nurse Practitioner. One third of the required hours were to be provided by the physician and there were only 6.75 physician hours documented. During the week of September 5 - 11, 2010 the census was 216 patients. There were 16 hours provided by the Certified Registered Nurse Practitioner and 0 physician hours. During the week of September 12- 18, 2010 the census was 216 patients. There were 32 hours provided by the Certified Registered Nurse Practitioner. One third of the required hours were to be provided by the physician. There were 0 physician hours documented for this time period. . This is a repeat citation from the on-site inspection conducted on October 20-22, 2009 for the approval to use a narcotic agent, specifically methadone.
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Plan of Correction
Director will increase Physican hours to meet State standards of 1 hour per week onsite for every 10 Patients. Director will also monitor weekly to ensure this deficency does not recur. |
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 22 patient records on November 2 through 4, 2010, the narcotic treatment program failed to have a narcotic treatment physician make a face-to face determination and document in the patient's record the basis for determining an individual's physiological dependence upon a narcotic drug in 5 of 10 records, as required.Findings:In the review of patient record documentation, it was determined that the writing on the face-to-face assessment form was completed by the Certified Registered Nurse Practitioner (CRNP), not the physician. In an interview with the facility director it was confirmed that the face-to-face assessment form contained the CRNP, not the physician's, handwriting. Further review of the documentation with the facility director confirmed that the physician was signing off as the preparer of the documentation that had been completed by the CRNP in patient records # 1, 3, 12, and 16. Additionally, in the review of patient record # 7, the record failed to include documentation of 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 one year prior to admission for maintenance treatment. This is a repeat citation from the on-site inspection conducted on October 20-22, 2009 for the approval to use a narcotic agent, specifically methadone.
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Plan of Correction
Director will monitor weekly to ensure the Soar Physican provide face to face determination of all patients for admission eligibility. Director met with the Physican and CRNP on 11/15/10, to discuss State regulation 715.9(a)(4)and to ensure that the regulation will be followed. |
715.9(b)(3)(i-ii) LICENSURE Intake
(b) Exceptions to the requirements in subsection (a) are:
(3) A patient who has been treated and later detoxified from comprehensive maintenance treatment may be readmitted to maintenance treatment, without evidence to support findings of current physiologic dependence, up to 2 years after discharge, if the following conditions are me:
(i) The narcotic treatment program attended is able to document prior narcotic drug comprehensive maintenance treatment of 6 months or more.
(ii) The admitting narcotic treatment physician, exercising reasonable clinical judgment, finds readmission to comprehensive maintenance treatment to be medically justified.
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Observations
Based on the review of twenty-two patient records and an interview with the facility director and clinical supervisor, three patients were readmitted to the program. Two of three patient records failed to included current and updated clinical information in the record.The findings include:Twenty-two patient records were reviewed. The records failed to include current and updated clinical information in patient records # 8 and 10.Patient # 8 was readmitted on August 2, 2010. The patient record contained outdated information, dated April 17, 2009, pertaining to the patient's drug and alcohol history, personal history and psychosocial evaluation. Patient # 10 was readmitted on July 7, 2010. The patient record contained outdated information, dated March 11,2009, pertaining to the patient's drug and alcohol history, personal history and psychosocial evaluation. An interview with the Clinical Supervisor and Facility Director confirmed that the documentation was not updated in the patient records upon patient readmission.
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Plan of Correction
Director and Clinical Supervisor will review and train all clinical staff on readmission procedures. Clinical Supervisor will review all documents prior to all patients readmitted to the program. Clinical Supervisor will monitor all readmissions weekly to ensure this deficiency does not recur. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on the review of patient records, the physician's time sheets, and patient and staff interviews, the facility failed to restrict the dose reviews to the narcotic treatment physician in six of six patient records.The findings include:Twenty-two patient records were reviewed on November 2-4, 2010. Six patient records were reviewed for documentation by the narcotic treatment physician to determine the proper dose level for the patient. Six patient records contained documentation that the Certified Registered Nurse Practitioner (CRNP) completed the dose changes in patient records # 1 ,3, 4, 12, 16, and 22.Patient record # 1 had a verbal order and dose review documented by the CRNP on 9/8/2010. The physician signed the order on 9/8/2010; however, there was no documentation to verify the physician was at the clinic this day. Patient record # 3 had verbal orders and dose reviews documented by the CRNP on 9/9/2010, 9/15/2010, and 9/17/2010. The physician signed off on each order on 9/9/2010, 9/15/2010 and 9/17/2010 respectively; however, there was no documentation to verify that the physician was at the clinic this day. Patient record # 4 had verbal orders and dose reviews documented by the CRNP on 9/9/2010 and 9/15/2010. The physician signed off on both orders on 9/9/2010 and 9/15/2010; however, there was no documentation to verify that the physician was at the clinic this day. Patient record # 12 had a verbal order and dose review documented by the CRNP on 9/14/2010. The physician signed off on the order on 9/14/2010; however, there was no documentation to verify that the physician was at the clinic this day. Patient record # 16 had the initial dose order in the CRNP's handwriting on 8/4/2010. The physician signed off on this order. Patient record # 22 had a verbal order and dose review by the CRNP documented on 9/15/2010 that read, "On 9/15/2010 patient #83, SF, to receive a dose of 110 mg of methadone, to drink in the clinic and will receive an additional dose of 60 mg. Patient to continue dosing following the below schedule." The CRNP signed off on receiving this order and the physician signed off on this order on 9/15/2010; however, there was no documentation to verify that the physician was at the clinic this day. Patient interviews were conducted on November 4, 2010. During the interview, it was confirmed that the CRNP was providing dose changes. Additionally, an interview with the facility director also confirmed that the documentation that was being reviewed indicated the CRNP was making dose reviews and not the physician. This is a repeat citation from the on-site inspection conducted on October 20-22, 2009 for the approval to use a narcotic agent, specifically methadone.
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Plan of Correction
Director will increase and monitor Physician hours weekly in order to provide dose reviews for all patients as needed.On 11/19/10, the Director met with Physician and CRNP to review and discuss State regulation 715.15(b), to ensure that only the Physician will provide dose reviews. Director will monitor on a weekly basis. |
715.15(d) LICENSURE Medication dosage
(d) A narcotic treatment program shall label all take-home medication with the patient 's name and the narcotic treatment program 's name, address and telephone number and shall package all take-home medication as required by Federal regulation.
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Observations
Based on observation, it was confirmed that the take-home medication label had inaccurate information documented.The findings include:On November 4, 2010, the dosing procedures were observed. Five patients received take-home bottles during the observation of dosing procedures. All the labels were reviewed for accurate information. Four out of the five take-home labels had the Certified Register Nurse Practitioner as the physician documented on the label, specifically for patient's # 4,17, 21. and 22.
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Plan of Correction
Director will monitor weekly to ensure all take-home lables have all information required by Federal regulation.Director met with Physician and CRNP on 11/19/10, to review and discuss State regulation 715.15(d) to ensure effective immediately, that only the Physician not the CRNP name is on the labels. Also the CRNP will no longer have Physician privileges in our system. All prior labels with the CRNP will be change to reflect the Physician name. |
715.16(a)(2) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(2) The narcotic treatment physician shall make this determination after consultations with staff involved in the patient's care.
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Observations
Based on review of patient records, the facility failed to ensure the physician made the determination for take home privileges in nine of nine records.The findings include: Twenty-two patient records were reviewed on November 2-4, 2010. Nine records were reviewed for physician determination of patient take home provision. Nine records indicated that the physician was not making the determination for take home privileges.It was documented in patient record # 2 on 10/28/2010-10/31/2010 "Patient is granted four day take home as an exception per MD and Administration due to vacation." Additionally, on 9/6/2010, there was a verbal order that stated, "Patient take home privileges and is allowed to receive three extra take home since Monday is a Holiday (Labor Day) Physician notified." The patient record also had documented on 1/22/2010, "Program Manager was notified about discrepancy. As per program manager, patient qualifies to receive an additional take home for Sunday from Soar to not interfere with his schedule. Physician notified." On 9/4/2009 it was documented in the patient record, " Discussed with director. Patient qualifies to receive five take homes in a row not to interfere with his regular permanent take home schedule. Physician notified."It was documented in patient record # 6 on 7/21/10 for the justification of a take home dose, "Due to holiday on Monday (July 4th) patient is allowed to have one extra take home as per program manager. Physician notified."It was documented in patient record # 7 that the Certified Registered Nurse Practitioner signed off on 2/18/2010 for two take home requests from 2/19/2010-2/22/2010. Additionally, it was documented in this patient record on 2/7/2010, "Patient is eligible for one day take home as an exception due to travel per administration."It was documented in patient record # 13 on a case conference note dated 7/14/2010 that the client was approved for a take home to go to local amusement park. The physician was not involved in the decision. Patient record # 17 on 2/9/2010 and 9/2/2010 contained a take home order that was signed by the Certified Registered Practitioner. The doctor countersigned the order that was determined by the Certified Registered Nurse Practitioner. It was documented in patient record # 18 that the Certified Registered Nurse Practitioner signed an order on 12/13/09 for a take home schedule change from weekly to bi-weekly.It was documented in patient record # 19 that the Certified Registered Nurse Practitioner approved a take home request for one snow emergency take home on 2/8/2010. Also, there was a case conference note that specified that patient will be granted a second take home dose and the physician was not present at case conference to make the determination. It was documented in patient record # 20 on 10/9/2010, "Patient to receive take home exception starting on 10/9/10 ending on 10/9/2010 for a total of one exception dose. Patient is granted one day take home as an exception due to work per MD and administration."It was documented in patient record # 21 on 9/10/2010 that the take home was granted per administration and was signed off by the CRNP. This is a repeat citation from the on-site inspection conducted on October 20-22, 2009 for the approval to use a narcotic agent, specifically methadone.
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Plan of Correction
Director and Clinical Supervisor will meet with all staff for in-service training to review take-home regulations and procedures, in-order for the Physican to determine eligibility. Director will monitor weekly. |
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 that the physician documented in the patient record the rationale for granting take home medication in four of nine patient records.The findings include:Twenty-two patient records were reviewed on November 2-4, 2010. Nine records were reviewed for take home medication rationale by the doctor. Patient records # 2, 6, 7, and 13 did not have the physician's rationale for granting the take home medication.Patient record # 2 failed to include documentation of the doctor's rationale for the take home privileges. The justification documented in the record on 9/6/2010 for the take home privileges provided was due to family vacation and Labor Day.Patient record # 6 failed to include documentation of the doctor's rationale for the take home privileges. The justification documented in the record on 7/2/2010 for the take home privileges provided was due to the July 4th holiday.Patient record # 7 failed to include documentation of the doctor's rationale for the take home privileges. The justification documented in the record for the take home privileges provided on 2/20/2010 and 2/21/2010 were due to the patient taking a family vacation.Patient record # 13 failed to include documentation of the doctor's rationale for the take home privileges. The justification documented in the record on 2/13/2010 for the take home privileges provided was the President's Day holiday, on 7/14/10 a take home was approved for going to a local amusement park, on 2/5/2010 a take home was approved for an Emergency exception, and on 4/2/2010 a take home was approved for a Religious holiday (Good Friday).
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Plan of Correction
Director will meet with Physician on 12/10/10, to discuss and ensure the Physician document in the patient record the rationale for granting take home medication. Director will monitor weekly to ensure this deficiency does not recur. |
715.16(b)(1-8) LICENSURE Take-home privileges
(b) The narcotic treatment physician shall consider the following in determining whether, in exercising reasonable clinical judgment, a patient is responsible in handling narcotic drugs:
(1) Absence of recent abuse of drugs (narcotic or non-narcotic), including alcohol.
(2) Regular narcotic treatment program attendance.
(3) Absence of serious behavioral problems at the narcotic treatment program.
(4) Absence of known recent criminal activity.
(5) Stability of the patient 's home environment and social relationships.
(6) Length of time in comprehensive maintenance treatment.
(7) Assurance that take-home medication can be safely stored within the patient 's home.
(8) Whether the rehabilitative benefit to the patient derived from decreasing the frequency of attendance outweighs the potential risks of drug diversion.
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Observations
Based on a review of patient records and staff interviews, the facility failed to provide physician documentation regarding the consideration for take-home privileges in one of four patient records.The findings include:Twenty-two patient records were reviewed on November 2-4, 2010. Four patient records were reviewed for compliance with the regulations regarding take-home medications. The facility's physician failed to document the consideration for take-home privileges in patient record # 13.Patient # 13 was admitted into treatment on March 11, 2009. On February 17, 2010, a take home dose change request form that addressed the criteria for take home privileges was signed by the Certified Registered Nurse Practitioner and not the physician. The facility director was interviewed on November 4, 2010. He was shown the dose change request form and confirmed that the Certified Registered Nurse Practitioner had signed the forms where the physician was to have signed.
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Plan of Correction
Director will meet with the Physican and monitor weekly to ensurs State regulations are followed when determining take-home privileges. |
715.16(e) LICENSURE Take-home priveleges
(e) With an exception granted under subsection (d), a narcotic treatment program may not permit a patient to receive more than a 2-week take-home supply of medication.
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Observations
Based on a review of patient records and an interview with the facility director, the facility failed to follow this standard by allowing a patient to have more than a 2-week take home supply of medication.The findings include:Twenty-two patient records were reviewed November 2-4, 2010. One patient record had documentation that the client had been granted an exception to include a total of sixteen take home doses which exceeded the 2-week supply of medication. Additionally, there was no documentation in this patient's record that an exception request had been sent in to the Department of Health for approval. Patient record # 2 had the following documentation included in the patient record:"Effective Date: 6/26/2010, (Patient # 2) to receive a take home exception starting 6/26/2010 and ending 7/11/2010 for a total of 16 exception doses.Justification: "Patient has 10 regular take homes and is granted six additional take homes for family vacation." This was signed by the doctor.
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Plan of Correction
Director will meet with all medical staff to ensure a patient never receives more than a six day take-home supply of medication without an exception from the State Department of Health. Clinical Supervisor will monitor and sign-off on each take home request, if the take-home request exceed regulations, it will first be reviewed and approved by the state unless they have a medical issue then the state will be notified. This is to ensure this deficency does not recur. |
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 and an interview with the Facility Director, the facility failed to ensure that the narcotic treatment physician determined the proper dosage level in 6 of 6 patients. Additionally, the narcotic treatment physician must document orders in accordance with applicable Federal and State Statues and regulations.The findings include:Twenty-two patient records were reviewed on November 2-4, 2010. Six patient records were reviewed for the physician's documentation in determining the proper dose. Six out of six patient records, specifically, 1, 2, 4, 5, 8, and 14 had standing orders documented for determining the patient's dose. Additionally, the physician signed a verbal order in patient records # 1, 3, 4, 12, 14, 20 and 22 on days that there was no documentation provided to verify that the physician was at the facility on the date that they were signed.Patient #1 received an initial dose of 30 mg. Documented in the patient record #1 was an order by the physician that included a standing order: Dose on 7/1/2010 of 30 mg methadone and continue according to schedule below:7/2/10 40 mg 7/7/10 55 mg7/3/10 45 mg 7/8/10 60 mg7/4/10 50 mg 7/9/10 60 mg7/5/10 50 mg 7/10/10 65 mg 7/6/10 55 mgThere was no documentation that the narcotic treatment physician continued to assess the patient to determine if an increase in the patient's dose was needed. The physician signed off on a verbal order in patient record #1 on 9/8/2010 and there was no time sheet available to verify that the doctor was at the facility on this date.Documented in the patient record # 2 was an order by they physician that included a standing order: Patient #2 to receive dose on 10/21/10 of 69 mg methadone and continue according to the schedule below:10/24/10 68 mg 11/11/10 62 mg10/27/10 67 mg 11/14/10 61 mg10/30/10 66 mg 11/17/10 60 mg11/02/10 65 mg 11/20/10 59 mg11/05/10 64 mg 11/23/10 59 mg11/08/10 63 mgThere was no documentation that the narcotic treatment physician continued to assess the patient to determine if an increase in the patient's dose was needed. The physician signed off on a verbal order in patient record #3 on 9/9/2010, 9/15/2010 and 9/17/2010, bu there were no time sheets available to verify that the doctor was at the facility on these dates.Patient # 4 received an initial dose of 30 mg. Documented in the patient record # 4 was an order by the physician that included a standing order, "Patient # 4 to receive dose on 7/23/10 of 30 mg methadone and continue according to the below schedule":7/24/10 35 mg 7/28/10 45 mg7/26/10 40 mg 7/30/10 50 mgThere was no documentation that the narcotic treatment physician continued to assess the patient to determine if an increase in the patient's dose was needed. The physician signed off on a verbal order in patient record #4 on 9/9/2010 and 9/15/2010 but there were no time sheets available to verify that the doctor was at the facility on these dates.Patient # 5 received an initial dose of 30 mg. Documented in the patient record # 5 was an order by the physician that included a standing order, " Patient #5, to receive dose on 3/17/2010 of 30 mg of methadone and continue according to the below schedule":3/18/2010 40 mg3/19/2010 45 mg3/20/10 45 mgInitiate titration, reevaluate in five days. There was no documentation that the narcotic treatment physician continued to assess the patient to determine if an increase in the patient's dose was needed. Patient # 8 was a transfer client and received an initial dose of 80 mg. Documented in the patient record # 8 was an order by the physician that included a standing order. "Patient # 8 to receive a dose on 8/2/2010 of 80 mg of methadone and continue according to below schedule":8/3/10 85 mg8/8/10 90 mgThere was no documentation that the narcotic treatment physician continued to assess the patient to determine if an increase in the patient's dose was needed. The physician signed a verbal order in patient record #12 on 9/14/2010; there was no time sheet available to verify that the doctor was at the facility on this date.Patient # 14 received an initial dose of 20 mg. Documented in the patient record # 14 was an order by they physician that included a standing order:7/14/10 25 mg 7/17/10 40 mg7/15/10 30 mg 7/19/10 45 mg7/16/10 35 mg 7/21/10 50 mgThere was no documentation that the narcotic treatment physician continued to assess the patient to determine if an increase in the patient's dose was needed.The physician signed off on a verbal order in patient record #14 on 7/8/2010, but there was no time sheet available to verify that the doctor was at the facility on this date.The physician signed off on a verbal order in patient record #20 on 9/8/2010, but there was no time sheet available to verify that the doctor was at the facility on this date.The physician signed off on a verbal order in patient record #22 on 9/15/2010, but there was no time sheet available to verify that the doctor was at the facility on this date.
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Plan of Correction
Director met with all medical staff the week of 11/15/10, to train and discuss policies and procedures regarding verbal medication orders, effective 11/22/2010. Director will monitor weekly to ensure deficiency does not recur. |
715.20(4) 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.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on the review of patient records and an interview with the facility director, the facility failed to document that it notified the referring facility of the admission and initial dosing of the patient in 5 of 6 patient records.The findings include:Twenty-two patient records were reviewed November 2-4, 2010. Six patient records were reviewed for documentation of notification to the referring facility of the admission and dosing of the referred patient. Patients # 1, 2, 6, 7, and 12 were referred by another narcotic treatment program and there was no documentation of the referral being notified of the admission and initial dosing of the patients. An interview with the facility director on November 4, 2010 confirmed that there was no documentation notifying the referring agency of the patient transfer and initial dose.
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Plan of Correction
Director and Clinilal Supervisor will meet with all clinical staff for in-service training to review policies and procedures regarding proper transfer of patients to another narcotic treatment clinic. Director will review all patient transfer-in files on day of admission. |
715.22(a) LICENSURE Patient grievance procedures
(a) A narcotic treatment program shall develop and utilize a patient grievance procedure.
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Observations
Based on review of administrative documentation and an interview with the project director, the facility failed to have a file with patient grievances.The findings include:A review of administrative documentation was conducted on November 4, 2010. A copy of the facility's grievance file was requested. The facility failed to provide a grievance file during the monitoring inspection. An interview with the project director confirmed that the grievance file was unable to be located.
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Plan of Correction
Director will ensure this facility have a Patient Grievance File on site at all times. Director will meet with all staff for in-service training to review policies and procdures referring to patient grievance. A file will be made and kept in the director's office to not be removed without the director's knowledge. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on the review of patient records, the narcotic treatment program failed to document the results of annual reevaluations by the narcotic treatment physician in one of two patient records.The findings include:Twenty-two patient records were reviewed on November 2-4, 2010. Annual reevaluations by the narcotic treatment physician were required in two patient records. The narcotic treatment program failed to document the results of the annual reevaluation by the narcotic treatment physician in patient record #2. Patient # 2 was admitted to the program on 2/12/2009. The annual reevaluation by the narcotic treatment physician was due by 2/12/2010. The annual reevaluation was not completed until 10/21/2010. The reevaluation was not completed by the doctor, it was completed by the Certified Registered Nurse Practitioner (CRNP) and was eight months late. An interview with the project director confirmed the CRNP documentation.This is a repeat citation from the on-site inspection conducted on October 20-22, 2009 for the approval to use a narcotic agent, specifically methadone.
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Plan of Correction
Director will meet with all medical staff and monitor to ensure the results of annual reevaluation are documented by the Physican in all patient charts. |
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 the review of patient records and administrative documentation, the facility failed to ensure the psychosocial evaluations were a clinical assessment of the historical data collected or completed within the policy-stated 10 days of admission. The findings include:Twenty-two patient records were reviewed on November 2-4, 2010. Eight patient records were reviewed for psychosocial evaluations. Patient records # 5, 6, 7, 8, 10, 14, and 15 had psychosocial evaluations that did not include a clinical assessment. The documents that were completed contained a repeat of the data and patient reported commentary without the clinician's impressions.
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Plan of Correction
Director and Clinical Supervisor will meet with all clinical staff for in-service training to ensure psychosocial evaluations are properly completed within ten days of admission, how not to repeat historical information in the clinical assessment of the history. Clinical Supervisor will review and sign-off on each evaluation, and will monitor weekly. |
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 narcotic treatment program failed to document support services in the comprehensive treatment plan in 8 of 11 patient records.The findings include:Twenty-two patient records were reviewed November 2-4, 2010. Treatment plans with support services were required in eleven patient records. The narcotic treatment program did not document support services in the comprehensive treatment plan in patient records # 8, 13, 14, 15, 16, 17, 18, and 19.
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Plan of Correction
Director and Clinical Supervisor will meet with clinical staff for in-service training on documenting support services in the comprehensive treatment plans.Clinical Supervisor will monitor weekly. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on review of administrative documentation provided during the inspection and staff interviews, the facility failed to submit documentation of unusual incidents to the Department as required. The findings include:A review of the incident report log was completed on November 3, 2010. The facility had an incident in October where there was extensive water damage at the facility. The facility failed to submit a written incident report to the department.Patient was found on the floor, on June 6, 2010 and the patient went to the hospital and was admitted. The facility failed to submit an incident report to the department.Patient was found on the floor and admitted drug use on 6/8/2010. Patient went to the hospital. The facility failed to submit an incident report to the department.This is a repeat citation from the on-site inspection conducted on October 20-22, 2009 for the approval to use a narcotic agent, specifically methadone.
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Plan of Correction
Director will meet with all staff for in-service training to ensure policies and procedures are followed regarding unusual incident reporting. All reports will be submitted to the Director within 24hours for submission to the State within 48hours. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records, the facility's administration failed to provide documentation that all personnel are trained in the use of the fire extinguishers upon employment.The findings include:Three personnel records were reviewed on November 2, 2010. Two out of three personnel records failed to have documentation that the employees were trained to use fire extinguishers upon staff employment, specifically employee # 1 and 2.Employee # 1 was hired on September 18, 2010. The document that the employee signed for receiving fire extinguisher training was not dated therefore it was unable to be determined as to whether this employee received the training upon employment.Employee # 2 was hired on October 11, 2010. There was no documentation that showed that this employee was instructed in the use of fire extinguishers upon employment
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Plan of Correction
Director will ensure all prior and new staff receive fire saftey training. On 11/10/10 all staff received an in-service training on how to use fire extinguishers. Documentations are placed in thier personnel files. All new staff will recieved this training upon employment.Director will monitor on-going. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of personnel records, the facility's administration failed to provide documentation that confirmed that all personnel are trained to perform assigned tasks during emergencies.The findings include:Three personnel records were reviewed on November 2, 2010. Two out of three personnel records failed to have documentation that the employee was trained for emergencies, specifically employee # 1 and 2.Employee # 1 was hired on September 18, 2010. The document that the employee signed for receiving emergency training was not dated therefore it was unable to be determined as to whether this employee received the training within the required timeframe.Employee # 2 was hired on October 11, 2010. There was no documentation that showed that this employee received emergency training.
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Plan of Correction
Director will ensure all staff receive in-service training to perform assigned tasks during emergencies.On 11/10/10 all staff received an in-service training to be able to perform assigned tasks during emergencies. All new staff will received this training upon employment and documented in their personnel file. Director will monitor on-going. |
709.26(f) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
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Observations
Based on the review of personnel records, the facility failed to have job descriptions signed in two of three personnel records reviewed.The findings include:Three personnel records were reviewed on November 2, 2010. Two out of three records reviewed failed to have a signed job description in their personnel records, specifically records # 1 and 2.
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Plan of Correction
Director will ensure all staff receive and sign job descriptions and placed in their personnel records. All personnel files were checked and staff that did not have job descriptions, received and signed them to be placed in their files. Director will ensure new staff will have them upon hire. |
704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on the review of personnel records the facility failed to maintain documentation of a staff needs assessment in one of two required records.The findings include:Three personnel records were reviewed on November 2, 2010. Two records required an assessment of staff training needs. Employee # 1 was hired September 18, 2010. The training needs assessment form was signed on September 18, 2010 but the form failed to have the training needs assessment portion completed.
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Plan of Correction
Director will ensure all staff receive and complete a training needs assessment. Director will meet with all staff to discuss and complete the training needs assessment form and place it in their personnel file. Director will monitor on-going and ensure all new staff complete upon hire. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on the review of personnel records the facility failed to have an individual training plan in one of two required records.The findings include:Three personnel records were reviewed on November 2, 2010. Two records required an individual training plan within thirty days of hire. Employee # 1 was hired September 18, 2010; the individual training plan was due by October 18, 2010. The individual training plan form was signed on September 18, 2010 but the portion of the form that indicated what training needs were being requested by the staff was not documented.
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Plan of Correction
Director will ensure all staff receive and complete an individual training plan appropriate to the employee's skill level, then annually thereafter. All new staff will complete upon hire. Director will monitor on-going. |