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 October 20-22, 2009 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 4 PA Code and 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on November 8, 2009.
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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 1 hour of physician time for each 10 patients enrolled for services during one of thirteen weeks reviewed.
The findings include:
Physician and Certified Registered Nurse Practitioner (CRNP) time sheets and and census reports ( administrative documentation) for the months of July, August, September and October to date were reviewed on October 21, 2009. The facility is licensed to medicate 245 patients and the census did not go below 150 patients during the time period reviewed.
There were insufficient onsite physician hours during September. During the week of September 21-27, 2009, there were no physician hours documented. The CRNP was away and no time sheet was documented for the physician.
The insufficient physician hours were discussed with the regional director on October 21, 2009.
The back up physician time sheet was presented for 6 hours without any dates and was therefore not used to calculate the physician time.
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Plan of Correction
Director will locate a Doctor and CRNP to act as backups when needed. Director will have letters of agreement in place with 2 doctors to cover hours when needed. Both Dr B and Dr T will receive letters and have already verbally agreed to give SOAR so many hours a week as needed. Director will also send letter to other NTP's in this area asking if an agreement can be made between the 2 agencies to offer coverage when needed. Director will monitor payroll sheets for compliance every 2 weeks. |
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 facility failed to ensure the physician made a face to face determination of current and one year addiction history in 3 of 4 patient records reviewed.
The findings include:
Thirteen patient records were reviewed October 20-21, 2009. Four records were reviewed for physician's face to face determination of addiction.
Patient record # 6 contained documentation the Certified Registered Nurse Practitioner (CRNP) made the determination.
Patient record # 12 did not have any documentation other then the physical exam, which was completed by the CRNP and was not signed by the physician.
Patient record # 13 contained an undated form of addiction, making it impossible to know if the determination was completed prior to the administration of the agent.
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Plan of Correction
Director will issue memo to Medical staff clearly indicating what the expectations are for a new admission to SOAR and that a Doctor must do a face to face with a patient to determine addiction to opiates. Clinical Supervisor will monitor all new admits within 10 days of admission to ensure compliance to this regualation. |
715.10(d) LICENSURE Pregnant patients
(d) Within 3 months after termination of pregnancy, the narcotic treatment physician shall enter an evaluation of the patient 's treatment status into her record and state whether she should remain in comprehensive maintenance treatment or receive detoxification treatment.
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Observations
Based on a review of patient records, the facility failed to document, within three months after the termination of pregnancy, whether or not the patient should continue maintenance or receive detoxification treatment in one of one patient record.
The findings include:
Thirteen patient records were reviewed October 20-21, 2009. An evaluation of the patient's treatment status within three months after termination of pregnancy was required in one patient record. The narcotic treatment program, specifically the physician, did not document this evaluation that was due by October 15, 2009 in record # 9.
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Plan of Correction
Director will issue memo to Medical staff regarding this regulation and what is required of them to do with pregnant patients. Nurse Manager will monitor for compliance in performing a chart review at the 90 day mark per the regulation. |
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 facility failed to ensure the physician documented a
consultation with the Certified Nurse Practioner (CRNP) before determining the patient's initial dose and
schedule in two of five patient records.
The findings include:
Thirteen patient records were reviewed on October 20-21, 2009. Five patient records were reviewed for
determination of initial dose by the physician.
Patient record # 6 was admitted by the CRNP on 2-23-09. The CRNP completed the physical exam and
ordered the initial 30 mg dose.
Patient record #12 was admitted 3-11-09. The CRNP completed the physical exam on 3-10-09. The
physician never signed or documented consultation. The CRNP documented a verbal order from the
physician to initiate a 20 mg dose.
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Plan of Correction
Director will issue memo and meet with Medical staff for in-service training to review admission regulations and procedures. Memo and meeting will clearly indicate what each has to perform as part of the admission and the initial dose of medication. Director and Nurse Manager will monitor for compliance. Clinical Supervisor will also review during all quarterly chart audits 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 a review of patient records, the facility failed to ensure the physician made the determination for take home privileges in one of three patient records.
The findings include:
Thirteen patient records were reviewed on October 20-21, 2009. Three records were record was reviewed for physician determination of patient take home provision. Patient record # 12 had the signature of the CRNP as the physician on the signature line for the physician.
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Plan of Correction
Director will issue memo and perform in-service trainig for all staff regarding take home regulations. Director will speak to and issue seperate memo to both MD and CRNP regarding signatures and who is responsible for what. Director and Clin Sup will monitor for compliance during regular chart audits during the year. |
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 three of four patient records.
The findings include:
Thirteen patient records were reviewed on October 20-21, 2009. Annual reevaluations by the narcotic treatment physician were required in four patient records. Three of the four annual physical exams were completed by the CRNP. The narcotic treatment program failed to document the results of the annual reevaluation by the narcotic treatment physician in patient records # 9, 10 and 11.
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Plan of Correction
Director will issue memo and perform inservice training for Medical staff regarding who is responsible to do what. CRNP will be given seperate memo detailing exactly what she can and cannot do in performing her responsibilities here at SOAR. Director and Clin Sup will monitor for compliance during regular chart audits during the year. |
715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
Based on the review of patient records, the facility failed to complete the required laboratory tests in four of four records reviewed.
The findings include:
Thirteen patient records were reviewed on October 20-21, 2009. Four patient records were reviewed for completed laboratory results.
Patient record # 3 was admitted on 1-9-09. There was no documentation of a blood serology or a tuberculosis mantoux test in the patient record at the time of the review.
Patient record # 7 was admitted on 3-6-09. There was no documentation of a blood serology or a tuberculosis mantoux test in the patient record at the time of the review.
Patient record # 12 was admitted on 3-11-09. There was no documentation of tuberculosis mantoux test in the patient record at the time of the review. The blood serology was completed 8-25-09, more than 5 months after admission.
Patient record # 3 was admitted on 3-25-09. There was no documentation of tuberculosis mantoux test in the patient record at the time of the review. The blood serology was completed 6-19-09, about 3 months after admission.
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Plan of Correction
Director will contact Tower systems to add prompts for this and other required documentation. In-service will be done by Director to ensure that all staff who provide direct services to a patient clearly understand what the expectations are and their respective time frames. Additionally, folder system for Dr to review test results will be changed by Director to a system that provides individual checklist for each patient. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on the review of patient records, the facility failed to document complete discharge summaries in 7 of 7 patient records.
The findings include:
Thirteen patient records were reviewed on October 20-21, 2009. Seven patient records were reviewed for discharge summaries. Patient records # 1, 2, 3, 4, 5, 6 and 7 did not contain what services were provided to the patient during the treatment process or the status of the patient upon discharge.
Patient records # 6 and 7 did not document the reason for the patient's admission. Patient records # 2, 3, 4, 5, 6 and 7 did not provide a summary of the overall treatment experience, but rather focused on the reasons for discharge or a general statement of patient's compliance and attendance.
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Plan of Correction
Clinical Supervisor will provide in-service training for all clinical staff regarding proper format / procedures in writing a discharge summary. Director and Clin Sup will review current form being used and make changes so that all of the pertinent info is included. Clin Sup will monitor for compliance during regular chart audits and by reviewing all discharge summaries done for next 90 days. |
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
Based on the review of patient records, the narcotic treatment program failed to document complete treatment plan updates in five of nine patient records.
The findings include:
Thirteen patient records were reviewed on October 20-21, 2009. Treatment plan updates were reviewed in nine patient records. The narcotic treatment program did not document in the treatment plan updates the patient's progress in relationship to the stated goals in patient records #1, 2, 4, 8 and 13. There were generalized progress statements not related to the goals and objectives. Goals were changed or dropped without any explanation.
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Plan of Correction
Director and Clin Sup will perform in-service training for all clinical staff regarding treatment plans. Focus will be on how to document progress utilizing individual goals and objectives. Clin Sup will review all treatment plans for compliance before signing. |
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:
The folder of unusual incidents was reviewed on October 20, 2009 and discussed with the clinical supervisor on October 21, 2009 and the facility director on October 22, 2009. There were multiple incidents of patients being sent to the hospital for possible overdoses from the clinic. These were not reported to the Department.
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Plan of Correction
Director will issue memo to all staff regarding incident reports and what MUST be reported to DAPL. Director will be informed of all incident reports by staff and/or Clin Sup regarding abuse, death or serious injury, disruption of services, events that could be negative in community and drug related hospitalization of a patient. Both director and clin Sup will monitor incident reports weekly and add this to agenda of weekly staff meetings. |