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 and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on December 4-6, 2012 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.
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Plan of Correction
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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 three of thirteen patient records reviewed.The findings include:Twenty five patient records were reviewed December 4-6, 2012. Thirteen patient records were reviewed for monthly urine drug screen results. Patient # 5 was admitted July 9, 2008. There were no urine drug screens in the patient file at the time of the review. Patient # 14 was admitted July 3, 2012 and was missing a urine drug screen for November 2012 at the time of the monitoring.Patient # 15 was admitted June 15, 2012. the patient was actually incarcerated and the facility obtained oral swabs for specimen testing. There were no documented urine drug screens for July or September 2012. There was no documentation of any reason the specimens were not obtained.
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Plan of Correction
Three patients were cited under this standard and because of differences in the circumstances there are two separate solutions being pursued.
Patient #5 was a discharged patient who did not have the drug screen results (121 specimens had been tested) included in the chart. It is customary for a complete record of drug testing to be updated inserted into the patient record at time of discharge. This was apparently not done in this case. To prevent this oversight in the future our protocol for discharge chart review has been upgraded to include a signed and dated checklist of essential documents, to be executed by the member of the clerical staff assigned to review charts for completeness. The Clinical Supervisor will review these sign off sheets at the end of each month for the discharges of the prior month and will follow up any indications that a chart is incomplete.
Patient #14 did not have any drug test results for the month of November, 2012. There were five separate unsuccessful attempts to obtain a urine specimen from this patient who was pregnant at the time. What should have happened is that within that period an oral specimen be collected for testing in lieu of a urine specimen. To correct this in the future the Nursing Supervisor will be reviewing a report generated on the 21st of each month that will identify any patients who have not yet been tested during that calendar month. It will be her responsibility to insure anyone on said report is scheduled for a test before then end of the month. Failure to provide a urine specimen in this context will result in the collection of an oral specimen to insure that a test can be done.
Patient #15 was incarcerated and pregnant for most of the period during which specimens were not collected and tested and in inpatient rehab for a significant portion of the time as well. While it is not clear if this contributed to specimens not being tested, the Nursing Supervisor will insure that the same procedure described in reference in Patient #14 above is applied to incarcerated patients.
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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 and a review of administrative documentation, the facility failed to review annually to determine whether the need for the exception for 13-day take-home still existed in three of three patient records reviewed.The findings include:Twenty five patient records were reviewed December 4-6, 2012. The Methadone Monitoring Questionnaire documented that fifteen patients at the facility had 13-day take home privileges due to permanent physical disability. Three records were reviewed for annual documentation that the 13-day take home privilege still existed. Three of three records failed to include documentation that the justification for 13-day take homes still existed, specifically in patient records # 21, 22 and 23.
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Plan of Correction
All patients currently granted 13-day takeout privileges due to disability will be reviewed by our Medical Director within 30 days. He will document this in the patient's record. Our Nursing Supervisor will verify that this has been done. Those same patients, if they are still eligible in January, 2014 will be reviewed then and annually thereafter. Any patients granted such privileges in the future will be evaluated on annually on the anniversary of their original approval. |
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 facility failed to complete the annual physical with a re-evaluation by the physician in six of seven patient records reviewed. for an annual physical with a reevaluation by the narcotic treatment physician.The findings include:Twenty five patient records were reviewed December 4-6, 2012. Seven patient records were reviewed for an annual physical with a reevaluation by the narcotic treatment physician.Six of the seven patient records contained documentation the Certified Nurse Practitioner (CRNP) completed the annual physical for patients # 11, 12, 16, 21, 22 and 23. While there were annual clinical evaluations also completed that included a status of the patient that was signed by the narcotic treatment physician, it was actually completed by the clinician.
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Plan of Correction
All annual physical examinations of patients in treatment for longer than one year will continue to be conducted by the nurse practitioner as permitted by this standard. In a separate document titled "Annual Patient Reevaluation" the narcotic treatment physician will indicate a review of all pertinent information regarding the patient's continued eligibility and appropriateness for methadone maintenance treatment, including the findings of the annual physical examination, the clinician's assessment of the patient's progress, lab tests or any other source deemed germane to the evaluation. The physician's signature on this document will indicate the physician alone has made the determination of the future course of treatment for the patient's opiate dependence. This modification of current procedure and documentation will commence within 30 days of the approval of this plan. The Nursing Supervisor will oversee this process going forward and insure that the documentation is properly executed. |