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 November 2 through November 4, 2010 methadone monitoring inspection. The follow-up inspection was conducted on April 27, 2011 by staff from the the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Soar Corp. 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 27, 2011.
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Plan of Correction
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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 and interviews, it was confirmed that the take-home medication label had inaccurate information documented.The findings include:On April 27, 2011, the dosing procedures were observed. There was a list of employees who were permitted in the dosing area. The list specifically stated that the former doctor was not longer employed at the facility. Take-home bottle labels were reviewed for accurate information. One bottle included the former doctor's name listed on the take-home label, specifically client # 15. An interview with the nursing staff, project director, and facility director confirmed that this was an issue with the current dosing system and the former doctor's name was printing on random take-home labels. The project director did correct this issue while methadone monitoring staff were on site.
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Plan of Correction
Director changed the list of people that are allowed in the dispensary and called Tower support to have the name of the doctor changed in the system both done. Director will monitor for compliance. |
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.Due to the fact that there were no new clients with take home privileges, this cannot be re-evaluated until the next monitoring inspection please resubmit the original plan of correction
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Plan of Correction
Meeting with Director and all Soar doctors will take place where Take Home regulation and requirements will be given out and discussed. All nurses informed that they are not to give a take home to any pt without a doctors order and approval. Soar no longer employs a CRNP. All staff informed by Director that only a doctor can give a take home under all circumstances. Memo issued to all staff by Director indicating that termination will be consequence for any staff member who can not comply in this area. Director will monitor for compliance throughout the year. Form will be developed by Director that will be used to track take homes given in the computer system. This report will be monitored at least once a month by Quality Improvement Team to check for compliance. |
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). Due to the fact that there were no new clients with take-home privileges this cannot be re-evaluated until the next monitoring inspection please resubmit the original plan of correction
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Plan of Correction
Director will have meeting with all doctors at Soar to discuss Pa take home requirements and how to write the order regarding the need for there to be a compelling reason for the take home. All staff informed through memo from Director that only a doctor can give a take home to a pt for any reason at all. Team meeting structure to be changed so that all take homes will be discussed in the team mtg before going to the doctor. director will monitor for compliance. |
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. Due to the fact that there were no new clients with take home privileges this cannot be re-evaluated until the next monitoring inspection please resubmit the original plan of correction.
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Plan of Correction
Soar no longer employs a CRNP. Dir and Clin Sup will meet with all staff for inservice training to review take home regs and procedures in order for Soar Dr to determine eligiblity reason(s). Dir will meet with all Soar doctors to discuss identifying rationale for granting a take home and how to document properly. Director will monitor both weekly for 90 days and then at least once a month thereafter. |
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 and an interview with the project director, the narcotic treatment program failed to document the results of annual reevaluations by the narcotic treatment physician in three of three patient records.The findings include:Fifteen patient records were reviewed on April 27, 2011. Annual reevaluations by the narcotic treatment physician were required in three patient records. The narcotic treatment program failed to document the results of the annual reevaluation by the narcotic treatment physician in patient records # 1, 2, and 9. Patient # 1 was admitted to the program on 2/23/2010. The annual reevaluation by the narcotic treatment physician was due by 2/23/2011. The annual physical exam was completed on 2/17/2011 by the Certified Registered Nurse Practitioner. A reevaluation was not completed by the narcotic treatment physician. Patient # 2 was admitted on 2/3/2009. The annual reevaluation by the narcotic treatment physician was due by 2/3/2010 and 2/3/2011 respectively. The project director was able to find documentation in the computerized record that indicated an annual physical was completed on 11/8/2010 (see paperwork in record). There was no documentation in the client record that annual physical examinations and annual evaluations were completed in the patient record for 2010 or 2011.Patient # 9 was admitted 3/10/2009. The annual reevaluation by the narcotic treatment physician was due by 3/10/2010 and 3/10/2011 respectively. There was no documentation in the client record that annual physical examinations and annual evaluations were completed in the patient records for 2010 and 2011.An interview with the project director confirmed that the documentation was not available.This is a repeat citation from the on-site inspections conducted on October 20-22, 2009 and November 2-4, 2010 for the approval to use a narcotic agent, specifically methadone.
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Plan of Correction
Director will have meeting with all Soar doctors where take home regulations, rules and our policies will be discussed and clarified. All staff given memo detailing the take home policy and that only a doctor can issue a take home and that a take home must be justified by the doctor in addition to the order.Soar no longer employs a CRNP. Director will monitor for compliance. |
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 the facility policy and procedure manual, staff interviews, and patient records reviews, the facility failed to ensure that the psychosocial evaluations were completed within the 10 day timeframe as per the facility policy and procedure manual four of four records reviewed.The findings include:The facility policy and procedure manual was reviewed on April 27, 2011 Fifteen patient records were reviewed. Four records were reviewed for psychosocial evaluations. The policy and procedure manual stated that the psychosocial evaluations should be completed within 10 days of admission. The facility failed to document a timely psychosocial evaluation in four of four patient records, specifically, # 4, 5, 6, and 14.Patient # 4 was admitted on 3/2/2011. The psychosocial evaluation was due by 3/12/2011. The psychosocial evaluation was not completed until 4/2/2011 and was 21 days late.Patient # 5 was admitted on 3/18/2011. The psychosocial evaluation was due by 3/28/2011. The facility failed to complete a psychosocial evaluation for this client as of the date of the inspection.Patient # 6 was admitted on 4/11/2011. The psychosocial evaluation was due by 4/21/2011. The facility failed to complete a psychosocial evaluation for this client as of the date of the inspection.Patient # 14 was admitted on 2/10/2011. The psychosocial evaluation was due by 2/20/2011. The psychosocial evaluation was completed on 2/22/2011 and was two days late.
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Plan of Correction
Director has changed Soar policy to allow up to 30 days to complete a psychosocial evaluation. Policies have been changed in 3 seperate policies per regulations. Clinincal supervisor will monitor counselors for compliance in this area through weekly supervision. |
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.
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Observations
Based on the review of patient records, the facility failed to complete annual evaluations in accordance with the regulations in four of four patient records reviewed. The findings included:Fifteen patient records were reviewed April 27, 2011. Four patient records required documentation of an annual clinical review that included the patients status. The annual evaluation should 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 the narcotic treatment program. Patient records # 1, 2, 8, and 9 failed to have an annual review documented in the record.Patient # 1 was admitted on 2/23/2010. The annual evaluation was due by 2/23/2011. The facility failed to have an annual evaluation documented in the patient record at the time of the inspection.Patient # 2 was admitted on 2/3/2009. The annual evaluation was due by 2/3/2011. The facility failed to have an annual evaluation documented in the patient record at the time of the inspection.Patient # 8 was admitted 2/22/2010. The annual evaluation was due by 2/22/2011. The facility failed to have an annual evaluation documented in the patient record at the time of the inspection.Patient # 9 was admitted 3/10/2009. The annual evaluation was due by 3/10/2011. The facility failed to have an annual evaluation documented in the patient record at the time of the inspection
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Plan of Correction
All staff to be informed of Soar policy and state requirements in doing annual evaluations for all active pts. This will be discussed in staff mtgs and addressed by Clin Sup in weekly supervision. Clin Sup will monitor for compliance |
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 employmentDue to the fact that this cannot be re-evaluated until the next licensing inspection please resubmit the original plan of correction.
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Plan of Correction
Director made this document part of the employment packet so that it will now be done on new employees first day of working at Soar. Director wil monitor for compliance throughout the year. |
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. Due to the fact that this cannot be re-evaluated until the next licensing inspection please resubmit the original plan of correction.
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Plan of Correction
Director will be responsible to make sure that all new emplyees are trained in what to do in an emergency at Soar. This will also become part of the new employee packet. Local emergency numbers and poison control number will be placed on all telephones. All new staff will be asked to attend the next mtg of the Health and Safety Committee which meets quarterly. Director will monitor for compliance throughout the year. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on the review of the policy and procedure manual the facility failed to document a preliminary treatment plan in two of two records.The findings include:The facility policy and procedure manual was reviewed on April 27, 2011. According to the facility policy and procedure manual the counselor will complete a preliminary treatment plan within 15 days of admission. Fifteen patient records were reviewed. Two records were reviewed for preliminary treatment plans. The facility failed to document a preliminary treatment plan in patient records # 5 and 6.Patient # 5 was admitted 3/18/2011. A preliminary treatment plan was due by 4/2/2011. The facility failed to have a preliminary treatment plan documented in the patient record at the time of the inspection. Patient # 6 was admitted on 4/11/2011. A preliminary treatment plan was due by 4/26/2011. The facility failed to have a preliminary treatment plan documented in the patient record at the time of the inspection.
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Plan of Correction
Director has informed all counselors that they are to meet with all new pts within five (5) days of admission. At that time the preliminary Tx plan will be done. This will be monitored by the Clin Sup through chart audits and weekly supervision. |