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 June 3,4, and 5, 2008 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 plan of correction is due on July 4, 2008.
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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 13 patient records, the facility failed to, with patient consent, contact the previous narcotic treatment facility for patient # 3's narcotic treatment history.
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Plan of Correction
An In-service training regarding by Patient Consent contacting the previous Narcotic Treatment Provider will be completed with all staff by the Director or Clinical Supervisor to enusre proper education obtaining documentation of treatment history for all new admissions. The Director will ensure the training is completed. The Clinical Supervisor will ensure ongoing compliance via chart audits completed quarterly. |
715.10(c) LICENSURE Pregnant patients
(c) Counseling records and other appropriate patients records shall reflect the nature of prenatal support provided by the narcotic treatment program.
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Observations
Based on a review of 13 patient records, the facility failed to document in one of two records applicable for this standard that the patient received prenatal support. Specifically, patient # 3 was pregnant when she entered treatment pregnant and, although documentation identified pregnancy, there was no inclusion of pregnancy and prenatal needs in the initial treatment plan.
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Plan of Correction
An in-service training will be provided by the director regarding treatment planning and prenatal follow-up of pregnancy for all clinical staff. The nurse practitioner will monitor for 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
The facility failed to maintain patient confidentiality with take-home bottles that were returned to the facility. Specifically, interviews with staff confirmed that returned take-home bottles with the patient's full name recorded on the bottle's label, were being thrown into general trash containers in the dispensing area without concealing the patient's name and other identifying information.
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Plan of Correction
The director ensure that the nurse manager is properly educated one confidentiality with take-home bottles to the facility. The nurse manager will also provide a memo to the dispensing staff regarding using a marker to black out identifiable information on all take-home bottles. The nurse manager will monitor for compliance. |
715.16(a)(5) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(5) A narcotic treatment program shall develop written policies and procedures relating to granting and rescinding take-home medication privileges.
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Observations
Based on a review of thirteen records, the facility failed to follow their policy and procedure when making take-home determinations in 1 of 2 patient records reviewed for take-home privilege eligibility. Specifically, patient # 8 was given weekend take-home privilege status despite having positive drug test results during the prior 90 days.
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Plan of Correction
The director will ensure that a memo regarding all policy and procedures will be provided to all staff regarding reductions in a clients medication schedule. The clinical supervisor will ensure that all take-home privileges are reviewed to determine clients appropriateness for take-home privileges. The primary therapist will be required to complete an eight point evaluation to ensure proper assessment of client for take-home bottles. The Medical Physician will have the final approval on all take home privileges. The clinical supervisor will monitor to ensure compliance. |
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 a review of 13 patient records, in 2 of 6 records reviewed for verbal medication order content the facility failed to follow their policy and procedure. Patient record # 1 contained documentation that the doctor issued a verbal order on 2/15/08 that went into effect on 2/17/08 but was not signed by the physician until February 27, 2008. Additionally, a verbal order issued for patient # 4 on 5/16/08 was never signed by the doctor.
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Plan of Correction
An in-service training will be provided by the director for the clinical and medical staff to review SOARS and DAPL policies and regulations regarding medication and verbal orders. The director will issue a memo with explicit directions and copies of policies will be given and reviewed with all staff. The director will issue a memo and follow-up for compliance. Verbal orders will be monitored daily for 30 days by the director and/or nurse practitioner. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on random review of 13 patient records and interviews with the medical staff, the facility failed to ensure the orders of the physician were being followed. Specifically, patient # 7 was to receive dose increases as ordered by the physician but instead received an increase not ordered by the physician.
The facility also failed to document that the physician was the person who determined patient doses, but rather had allowed nursing staff to recommend and write specific dose changes as revealed in the record of patient # 8. The nurse wrote a specific dose order that was signed by the physician. The physician must write the medication order and determine the correct dose.
Further, observation of patient dosing on June 5, 2008, revealed patients were permitted to come to the dosing window with open beverage containers, a violation of their policy and procedure pertaining to dosing protocol.
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Plan of Correction
An in-service training will be provided by the director for the clinical and medical staff to review SOARS and DAPL policies and regulations regarding medication and verbal orders. The director will issue a memo with explicit directions and copies of policies will be given and reviewed with all staff. The director will issue a memo and follow-up for compliance. Verbal orders will be monitored daily for 30 days by the director and/or nurse practitioner. |
715.23(b)(3) LICENSURE Patient records
(b) Each patient file shall include the following information:
(3) A complete medical history
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Observations
Of the thirteen patient records that were reviewed, seven were specifically reviewed for compliance with this standard. The facility failed to document a family medical history as required in patient records # 1 and 6.
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Plan of Correction
The director will ensure the program physician completes a family medical history as required in all patient records. The director will add a revision to the current medical history form to ensure all proper data is collected admission. The clinical supervisor will ensure documentation is completed by quarterly chart audits |
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
Of the thirteen patient records reviewed, eight records were reviewed for treatment plan content. In all eight records, the treatment plans contained global and non-specific goals; the contents did not address patient specific needs and goals as identified in the patient's personal history and psychosocial evaluation in patient records # 1, 2, 3, 4, 5, 6, 7, and 8.
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Plan of Correction
The director will ensure that the clinical staff is provided with additional training on treatment planning documentation. Documentation of the training will be forward each personnel file. The clinical supervisor will ensure that the treatment goals are measurable and will address any additional training needs in individual supervision. The Clinical supervisor will monitor for compliance. |
715.23(d)(1) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(1) The treatment plan shall identify the behavioral tasks a patient shall perform to complete each short-term goal.
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Observations
Of the 13 patient records that were reviewed, eight were were to determine compliance with the treatment plan content. The facility failed to develop treatment plans that contained short term goals with measurable steps. Further, the treatment plans failed to identify support services needed by the patient. Patient records # 1, 2, 3, 4, 5, 6, 7, and 8 contained vague, non-specific steps to reach the goals and the time frames were generalized rather than realistically specific to the action step; patient records # 1, 2, 3, 4, 5, 6, 7, and 8 had no support service documentation.
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Plan of Correction
A director will ensure that the clinical staff is provide additional training on treatment planning documentation. Documentation of training will be forwarded to each personnel file. The clinical supervisor will ensure that the treatment goals are measurable and address any additional training needs in individual supervision. The clinical supervisor will monitor to ensure compliance. |
715.23(d)(2) 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.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Of the 13 patient records that were reviewed, 3 records were reviewed for the content of the treatment plan update. The facility failed to document the progress or lack of progress in achieving the goals from the prior treatment plan in 2 of 3 records, patient # 1 and 5.
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Plan of Correction
Director and clinical supervisor will provide a in-service on proper documentation of clients progress in treatment plan update. Documentation of the training be forwarded to each personnel file. The clinical supervisor will ensure that treatment goals are measurable address any additional needs in individual supervision. Compliance with monitored by chart audits by the clinical supervisor. |