INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use narcotic agents, specifically methadone and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on May 24-26, 2010 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 and a plan of correction is due on June 24, 2010.
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Plan of Correction
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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 the review of patient records, the narcotic treatment program failed to document, within three months after the termination of pregnancy, whether or not the patient should continue methadone maintenance treatment or receive detoxification treatment in one of one patient record.The findings include:Eighteen patient records were reviewed May 25-26, 2010. An evaluation of the patient's treatment status within three months after termination of pregnancy was required in one patient record, # 13. The narcotic treatment program, specifically the physician, did not document this evaluation that was due by April 30, 2010. This is based on the patient's termination of pregnancy on January 30, 2010.
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Plan of Correction
All members of the counseling staff have already been notified in writing that it is their responsibility to record the approximate date of conception and termination of pregnancy regarding their patients and to bring all such cases to the first weekly staff meeting following termination of pregnancy. The Intake Coordinator has been charged with recording the approximate date of conception for any patients admitted already pregnant. The Information Technology Specialist who already produces a number of other reports that are reviewed during a weekly staff meeting has been instructed to generate another recently developed report that lists any patient whose recorded pregnancy termination date is within the 60 days prior to the report generation, or who has no termination date, but whose date of conception is more than 40 weeks earlier. The program physician will review all such cases at the first weekly staff meeting following termination of pregnancy and 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. The physician, at his or her discretion, may defer this decision for up to 2 months. In such instances it would again be the responsibility of the counselor to present the case for the doctor's review. All pregnancy termination dates are currently recorded. At the first weekly staff meeting of each new calendar month the Clinical Supervisor will generate the same list of all pregnancies terminated on the prior 60 days and verify that they have been presented for physician review and a determination has been made, and follow up to insure that they are presented, if they haven't already been.
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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 the review of patient records and discussion with nursing staff, the facility failed to demonstrate that the physician determined the dose and schedule in patient records reviewed.The findings include:Eighteen patient records were reviewed May 25-26, 2010. Physician orders are maintained in the electronic files for each patient. In reviewing the physician orders, it was noted that the schedule changes and exception doses are documented by the nursing staff rather than the physician. In an interview with the nursing supervisor, it was reported that these may be verbal orders, but there was no documentation that indicated they were verbal orders.
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Plan of Correction
Some verbal orders, usually for changes in schedule rather than dose were not subsequently signed by the physician and explicitly identified as verbal orders. This was due to an inadequate tracking process for insuring that such orders were consistently signed and identified as verbal. Since the inspection we have put into place a tracking process that enables us to insure that all such orders are correctly identified as verbal and subsequently signed. The members of the nursing staff have been instructed to record all verbal orders as such. The Nursing Supervisor now has the responsibility to print a list every morning of all the unsigned verbal medication orders from the prior day. She has also been instructed to contact the program physician and obtain all of the necessary signatures. The Program Director will generate a similar list at the beginning of each new month to confirm that all of the signatures have been executed. If there are any that have not been the Program Director will follow up with the Nursing Supervisor to correct the problem. She has also been charged with insuring that there is always a nurse on duty who will assume this responsibility in her absence.
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715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on the review of patient records, the facility failed to demonstrate all of the required information was included in the transferred patient files in two of three patient records.The findings include:Eighteen patient records were reviewed May 25-26, 2010. Three patient records required documentation of transfer information. Patient # 1 was transferred January 5, 2010. The facility failed to document the transfer of the patient's urine drug screen results, the patient's dose, status and any exception requests.Patient # 5 was transferred February 25, 2010. The facility failed to document the transfer of the patient's urine drug screens and status.
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Plan of Correction
Since the inspection we have implemented the use of a fax cover sheet specifically for sending records out to the receiving program in the case of patients transferring out. The cover sheet has a checklist of all the necessary documentation. The counseling staff has been instructed to use this cover sheet when sending records out. It requires the senders signature and requests the receiving program call the counselor back if there are any of the listed documents missing. The Clinical Supervisor currently reviews charts of patients discharged during the month. she has been instructed to identify all patients who were transferred out to another facility and confirm that this fax cover sheet is present and properly executed.
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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, the facility failed to document that notification was made to the referring facility of the admission and initial dosing of the patient in four of five patient records.The findings include:Eighteen patient records were reviewed May 25-26, 2010. Five patient records were reviewed for documentation of notification to the referring facility of the admission and dosing of the referred patient. Patient records # 11, 12, 13 and 14 were referred by another narcotic treatment program and there was no documentation of the referral source being notified of the admission and initial dosing of the patients.
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Plan of Correction
In the future the notification document informing a sending program that their patient has been accepted for admission and the date of the initial dose given to the patient will be sent by the Intake Coordinator. Members of the counseling staff have been instructed to look for this form in the intake paperwork when a case is assigned to them and to report it to the Clinical Supervisor if it is missing. In such cases, if they occur, the task would be referred back to the Intake Coordinator for completion. Additionally, the Clinical Supervisor will be instructed to include in her monthly chart review process, an examination of all charts from the prior month for patients who transferred into the program from other faciilties, specifically to confirm that the document verifying admission and initial dose to the sending program is included.
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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 patient records and staff interviews, the facility failed to submit documentation of a required unusual incident to the Department as required. The findings include:Eighteen patient records were reviewed May 25-26, 2010. Two patient records were discharged records and the patients were deceased. Patient # 7 was reported to have committed suicide in early January 2010. The facility did not report this to the Department as required.
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Plan of Correction
The text of this standard has been circulated to all members of the staff with instructions to complete and forward to the Program Director an Unusual Incident Report if any of the events described in this standard occur. The Program Director will fax a copy of any such reports to the Department. Currently, there is in place an incident reporting procedure that results in a written report generated by the staff members(s) witnessing an event that meets the threshold for internal reporting requirements. These requirements, while broader, are fully inclusive of the events defined in this standard. Those reports are forwarded to project and facility directors, as well as the nursing supervisor and the counselor of the patient(s) involved. In the future these reports will be reviewed specifically for whether or not the incident meets the reporting requirements of this standard, and indicate this determination on the report itself. These internal incident reports are currently reviewed at a monthly staff meeting that is attended by all administrative staff. This review, in the future, will specifically include confirmation that reporting required by this standard was completed in a timely fashion.
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