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 March 5, 6, and 7, 2012 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.
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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, the facility failed to provide at least one hour of physician time a week onsite for every ten patients for sixteen of seventeen weeks reviewed.The findings include:Physician time sheets and census reports were reviewed on March 5, 2012, for the months of November 2011, December 2011, January 2012, and February 2012. There were insufficient onsite physician hours during sixteen out of seventeen weeks. During the week of October 30 to November 5, 2011, the patient census was 303. The facility was required to provide at least 30.3 physician hours. There were 30 physician hours documented. The amount of physician hours documented did not meet the required hours.During the week of November 13 to 19, 2011, the patient census was 313. The facility was required to provide at least 31.3 physician hours. There were 30 physician hours documented. The amount of physician hours documented did not meet the required hours.During the week of November 27 to December 3, 2011, the patient census was 311. The facility was required to provide at least 31.1 physician hours. There were 30 physician hours documented. The amount of physician hours documented did not meet the required hours.During the week of December 4 to 10, 2011, the patient census was 310. The facility was required to provide at least 31 physician hours. There were 30 physician hours documented. The amount of physician hours documented did not meet the required hours.During the week of December 11 to 17, 2011, the patient census was 308. The facility was required to provide at least 30.8 physician hours. There were 30 physician hours documented. The amount of physician hours documented did not meet the required hours.During the week of December 18 to 24, 2011, the patient census was 307. The facility was required to provide at least 30.7 physician hours. There were 30 physician hours documented. The amount of physician hours documented did not meet the required hours.During the week of December 25 to 31, 2011, the patient census was 307. The facility was required to provide at least 30.7 physician hours. There were 30 physician hours documented. The amount of physician hours documented did not meet the required hours.During the week of January 1 to 7, 2012, the patient census was 305. The facility was required to provide at least 30.5 physician hours. There were 30 physician hours documented. The amount of physician hours documented did not meet the required hours.During the week of January 8 to 14, the patient census was 303. The facility was required to provide at least 30.3 physician hours. There were 30 physician hours documented. The amount of physician hours documented did not meet the required hours.During the week of January 15 to 21, the patient census was 305. The facility was required to provide at least 30.5 physician hours. There were 30 physician hours documented. The amount of physician hours documented did not meet the required hours.During the week of January 22 to 28, 2012, the patient census was 304. The facility was required to provide at least 30.4 physician hours. There were 30 physician hours documented. The amount of physician hours documented did not meet the required hours.During the week of January 29 to February 4, 2012, the patient census was 303. The facility was required to provide at least 30.3 physician hours. There were 30 physician hours documented. The amount of physician hours documented did not meet the required hours.During the week of February 5 to February 11, 2012, the patient census was 309. The facility was required to provide at least 30.9 physician hours. There were 30 physician hours documented. The amount of physician hours documented did not meet the required hours.During the week of February 12 to 18, 2012, the patient census was 306. The facility was required to provide at least 30.6 physician hours. There were 30 physician hours documented. The amount of physician hours documented did not meet the required hours.During the week of February 19 to 25, 2012, the patient census was 305. The facility was required to provide at least 30.5 physician hours. There were 30 physician hours documented. The amount of physician hours documented did not meet the required hours.During the week of February 26 to March 3, 2012, the patient census was 305. The facility was required to provide at least 30.5 physician hours. There were 30 physician hours documented. The amount of physician hours documented did not meet the required hours.The findings were reviewed with the facility director and the project director. The findings were not disputed.
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Plan of Correction
The doctor hours will be increased according to the census to ensure that the doctor works 1 hour for every 10 patients. A census sheet will be run at least 2 times a week to keep track of the hours. The Executive Director and/or Project Director will be responsible to oversee this is done. |
715.9(a)(1) 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:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on the review of patient records, the facility failed to provide documentation verifying that the individual had reached the age of 18 in two out of twenty-six charts. The findings include:Twenty-six patient records were reviewed on March 5-7, 2012. The facility's policy and procedure manual was reviewed on March 5, 2012. According to the facility's policy, they will obtain two forms of identification from the patient. One must be a state approved picture identification card with the patient's birth date. All patient records required documentation verifying the patient's age. Patient records # 7 and 13 did not have documentation.Patient # 7 was admitted on 9/17/2009. The documentation did not include verification of the age of the patient.Patient # 13 was admitted on 4/27/2011. The documentation did not include verification of the age of the patient.The findings were reviewed with the facility director and the project director. The findings were not disputed.
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Plan of Correction
There will be a change in the structure of who is responsible for the ID. The intake coordinator will be responsible at intake to collect two forms of ID as indicated in our policy. A State approved ID as in a drivers license or Pendot non drivers license will provide proof of age and identity, as well as a second form of ID. The clinical supervisors will be responsible that this is done and placed in the patients chart. Chart audits, as well as spot checks will be done by the clinical supervisors to assure this is accomplished. |
715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on the review of patient records, the facility failed to provide documentation of patient identity in all records. The findings include:Twenty-six patient records were reviewed on March 5-7, 2012. The facility's policy and procedure manual was reviewed on March 5, 2012. According to the facility's policy, they will obtain two forms of identification from the patient. One must be a state approved picture identification card with the patient's birth date. All patient records required documentation verifying patient identity. Patient records # 7 and 13 did not have documentation.Patient # 7 was admitted on 9/17/2009. The documentation did not include verification of the patient's identity.Patient # 13 was admitted on 4/27/2011. The documentation did not include verification of the patient's identity.The findings were reviewed with the facility director and the project director. The findings were not disputed.
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Plan of Correction
The new File room Coordinator will be responsible to rechack that the intake Coordinator placed copies of the ID in the patients charts for the 2 forms of ID, an official current PA state drivers licence or PENDOT non drivers ID card, and other forms of ID as specified in the SOAR policy and procedure manual. The clinical supervisors are responsibile to check that the ID's are in the patients chart via chart reviews and spot checks that will be done to assure compliance. This is a 3 way check process to assure complience. |
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 the review of patient records, the facility failed to provide documentation that the narcotic treatment physician made a face to face determination of whether the patient is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least one year prior to admission for maintenance treatment in one of eighteen patient records. The findings include:Twenty-six patient records were reviewed on March 5-7, 2012. Eighteen patient records were reviewed for documentation that the narcotic treatment physician made a face to face determination of whether the patient is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least one year piror to admission for maintenance treatment. The narcotic treatment physician failed to document this in patient record # 13.Patient # 13 was admitted on 4/27/2011. The documentation did not include a face to face determination by the physician.The findings were reviewed with the facility director and the project director. The findings were not disputed.
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Plan of Correction
New patients prior to the first Methadone dose, will have a face to face with the prescribing physician. The Soar staff physician will determin the patients dependency on Opiate use with a least a year history of Opiate use.
All new patients will be required to see the physician three times a week for the first 2 weeks of admission (more if needed). It will be the responsibility of the Clinical Director and/or the clinical supervisors to see this is achieved. The doctor will be notified of all new patients for priority scheduling. |
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 patient records, the facility failed to contact the previous narcotic treatment facility for the patient's treatment history in two of three patient records reviewed.The findings include:Twenty-six patient records were reviewed on March 5-7, 2012. Three patient records were reviewed for contact with a prior narcotic treatment program. Patient records # 23 and 25 did not contain documentation of prior treatment experience, nor was there evidence of attempts to secure this information.Patient # 23 was admitted on 2/24/2012. Documentation identified prior treatment occurring at a narcotic treatment program. The documentation in the patient record did not include contact with the prior narcotic treatment program.Patient # 25 was admitted on 2/22/2012. Documentation identified 2 prior treatment experiences at narcotic treatment programs. The documentation in the patient record did not include contact with the prior narcotic treatment programs.The findings were reviewed with the facility director and the project director. The findings were not disputed.This is a repeat citation from the September 20, 2011 unannounced follow-up inspection, as well as, a repeat citation from the May 18, 2011 methadone monitoring inspection.
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Plan of Correction
The intake coordinator will obtain a release from the patient to authorize prior treatment histories(if the patient approves). It's the responsiblity of the Intake Coordinator to send out a letter or fax to all MAT provider for prior treatment records and put documented proof in the chart that this information was requested.
The Clinical supervisors will be responsible to assess that this information was obtained or attempted to be obtained during chart aduits. |
715.10(b) LICENSURE Pregnant patients
(b) A narcotic treatment program shall give pregnant patients the opportunity for prenatal care either by the narcotic treatment program or by referral to appropriate health-care providers.
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Observations
Based on the review of patient records, the facility failed to document provision of prenatal care in two of four patient records.The findings include:Twenty-six patient records were reviewed on March 5-7, 2012. Four patient records were reviewed for the provision of referral for prenatal care. Patient # 7 was admitted on 9/17/2009. On 6/20/2011, the physician addressed her pregnancy documenting the patient was doing well and was to see OB/GYN for ultrasound. There was no further information found in the record to substantiate the patient was actually receiving prenatal care.Patient # 21 was admitted on 8/20/2010. On 12/17/2011, the counselor documented in a clinical note the patient was pregnant, currently 6 weeks and had an OB appointment on 12/19/2011. On 12/29/2011, the counselor documented in a clinical note the patient was pregnant and had a plan to follow up with the obstetrician. On 1/5/2012, the counselor documented in a clinical note the patient was pregnant and desired a healthy baby. On January 10, 2012, the counselor documented in a clinical note of the upcoming medical appointment due to a high risk pregnancy. On January 24, 2012, the counselor documented in a clinical note the patient was pregnant reporting an appointment. There was no further information found in the record to substantiate the patient was actually receiving prenatal care at the time of the documentation or since January 24, 2012.The findings were reviewed with the facility director and the project director. The findings were not disputed.
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Plan of Correction
The medical doctor, nurse or counselor will obtain information that a patient is pregnant. The doctor will get information on the patient and let the counselor know in treatment team meetings. The counselor will follow up with the patient by getting a release signed to be able to communicate with the PCP and/or OBGYN. The only information needed to be obtained is that the patient is getting prenatal care, and is generally in good health. The clinical supervisors will be responsible to see this is achieved by checking the charts in the monthly audit. There will be a training scheduled on Prenatal care notes on March 19, 2012. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on a review of patient records, the facility failed to obtain an informed, voluntary, written consent prior to the administration of a narcotic agent for maintenance treatment.The findings include:Twenty-six patient records were reviewed on March 5-7, 2012. Twenty-three patient records were reviewed for the completion of an informed, voluntary written consent prior to the administration of a narcotic agent. The facility failed to document the completion of an informed, voluntary, written consent prior to the administration of a narcotic agent in patient record # 7.Patient # 7 was admitted into treatment on September 17, 2009 and discharged on January 9, 2012. There was no documentation of an informed, voluntary written consent prior to the administration of a narcotic agent in patient record # 7.The project director confirmed this finding.
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Plan of Correction
All consent forms are now done pre admission by the Intake Coordinator.
The Intake coordinators were trained in a meeting with the Program Director and Supervisor on 3/16/2012. No patient can be doses prior to the admission process. The File Room Coordinator was also given the task on 3/16 to re-check all new admission charts for consent forms and list all charts missing consent forms,signatures and dates missing from the releases in the charts. The list will be given to the clinical supervisors. The Clinical Supervisors will be responsible for checking during supervisions and chart audits. |
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, the facility failed to demonstrate the physician made the determination of the patient's dose in eight of eight patient records.The findings include:Twenty-six patient records were reviewed March 5-7, 2012. Eight patient records were reviewed for physician's documentation of the patient's initial dose and schedule. Six of the twenty-six patients were new to the methadone program and needed to be inducted onto methadone. Two patients transferred in to the program and the doctor wrote a standard order for increases without assessing the patient prior to the increase. Patient # 2 was admitted to the facility January 30, 2012. The physician wrote a standing order for patient to be inducted starting with 20 mg on January 30, 2012, 25 mg on January 31, 2012, 30 mg on February 1, 2012, and 35 mg on February 2, 2012. Patient #12 was admitted to the facility December 12, 2011. The physician wrote a standing order for patient to be inducted starting with 30 mg on December 12, 2011, 40 mg on December 13, 2011, 45 mg on December 14, 2011, and 50 mg on December 15, 2011. Patient #16 was admitted to the facility January 12, 2012. The physician wrote a standing order for patient to be inducted starting with 30 mg on January 13, 2012, 40 mg on January 14, 2012, 50 mg on January 15, 2012, 55 mg on January 16, 2012, and 60 mg on January 17, 2012. Patient #18 transferred to the facility on February 29, 2012. The physician wrote a standing order for patient to be start with 50 mg on February 29, 2012, 60 mg on March 1, 2012, and 70 mg on March 2, 2012. Patient # 19 was admitted to the facility on August 29, 2011. The physician wrote a standing order for patient to be inducted starting with 30 mg on August 29, 2011, 35 mg on August 30, 2011, 40 mg on August 31, 2011, and 45 mg on September 1, 2011. Patient # 24 was admitted to the facility on January 27, 2102. The physician wrote a standing order for patient to be inducted starting with 30 mg on January 27, 2012, 35 mg on January 28, 2012, 40 mg on January 29, 2012, 45 mg on January 30, 2012, and 50 mg January 31, 2012.Patient # 25 was admitted to the facility on February 22, 2102. The physician wrote a standing order for patient to be inducted starting with 30 mg on February 22, 2012, 40 mg on February 23, 2012, 45 mg on February 24, 2012, and 50 mg on February 25, 2012. Patient # 26 transferred to the facility on January 13, 2102. The patient received 65 mg on January 17, 2012. The physician wrote a standing order for patient to be increased on January 23, 2012 starting with 70 mg on January 23, 2012, and 75 mg on January 24, 2012.A review of patient records # 2, 12, 16, 18, 19, 24, 25, and 26 revealed that there was no documentation by the admitting physician that addressed the rationale for an increase of methadone daily. On September 4, 2007, all narcotic treatment programs were issued a letter regarding methadone dose orders, especially during the induction phase, by the Department of Health & Human Services, Substance Abuse and Mental Health Services Administration: (SAMHSA) In part, the following is excerpted from the letter:"Because methadone overdose deaths have occurred in early treatment due to the drug's cumulative effects of the first several days, it is also important to be cautious when adjusting the dose. According to the drug labeling, the peak respiratory depressant effects of methadone typically occur later and persist longer than its peak analgesic effects, which can contribute to cases of iatrogenic overdose, particularly during treatment initiation and dose titration. With repeated dosing, "methadone may be retained in the liver and released slowly, prolonging the duration of action despite low plasma concentrations."The drug labeling also states that "steady-state concentrations are not usually attained until 3 to 5 days of dosing," and that doses "will 'hold' for a longer period of time as tissue stores of methadone accumulate." Therefore, patients should be closely monitored during the induction phase, and the increase in dose should be under the close supervision of a physician as stated in 42 CFR 8.12 (h)(4), ' Dosing and administration decisions shall be made by a program physician familiar with the most up-to-date product labeling'."The project director confirmed this finding.
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Plan of Correction
The doctor is not to use standing order for dosing new patients. The dose or dose increase is to be given by the doctor face to face with the patient. The doctor will present a 2 page sheet on the dangers of overdose.
The Chart room Coordinator will check that these sheets are signed dated and in the patients chart. The Clinical Director will be responsible to oversee the doctor is not using standard orders. The Supervisors will be responsible to check the Methadone safety forms are done and in the chart during chart audits. This procedure will be instituted by March 30, 2012. |
715.18(a)(3) LICENSURE Rehabilitative services
(a) A narcotic treatment program shall provide, either onsite or through referral agreements, a full range of rehabilitative services. Rehabilitative services shall include:
(3) Adult educational services.
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Observations
Based on the review of administrative documentation, the facility failed to document the facility provided adult educational services onsite or by a referral agreement. The findings include: Twenty-six patient records were reviewed on March 5-7, 2012. Administrative documentation that included referral agreements was reviewed on March 7, 2012. The facility failed to have a referral agreement for adult educational services. The Project Director confirmed this finding.
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Plan of Correction
SOAR is now an official Access to Recovery (ATR) Assessment site and has the ability to refer patients/clients to Literacy and Education/Adult basic classes, and/or GED preparatory classes. We have a primary ATR coordinator GIPRA/VMS trained)on staff at lease 3 days a week, as well as 3 other staff GIPRA trained.
A recovery specialist from the Philadelphia Office of Addiction Services under the ATR contract comes to SOAR on Wednesdays to track patients and vouchers. SOAR also has a proposal in to become a training center.
We have printed in our March Patient News letter that these services are available. We also put up signs informing patients of the service.
Our ATR Coordinator will have more information about the education services anounced at groups. And will be responsible for promoting the ATR services. We have the required 2 year Referral Agreement between SOAR and The Philadelphia Department of Behavioral Health in the Appendences. The Executive Director will be responsible for updating the agreement.
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715.21(1)(i-iv) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
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Observations
Based on the review of patient records, the facility failed to document all efforts to retain the patient in the program prior to initiating an involuntary termination in one of four patient records.The findings include:Twenty-six patient records were reviewed on March 5-7, 2012. Eight discharged patient records were reviewed. Four discharged records were reviewed for involuntary discharge. One patient was discharged for financial reasons.Patient # 20 was admitted October 20, 2011. On November 22, 2011, the patient's financial situation was reviewed on the "Patient Monthly Update Form." The form identified no current balance and absences from treatment for 11/15/2011 plus "excused from 11/23 - 11/30/11." On December 27, 2011, the patient's financial situation was reviewed on the "Patient Monthly Update Form." The form identified the patient "is current financially" and absences "excused from 12/1 to 12/12." On January 31, 2012, the patient's financial situation was reviewed on the "Patient Monthly Update Form." The form identified a $750 balance, "working with welfare to reinstate benefits" and absences from 1/8 to 1/12 with hospitalization from 1/13 to 1/23. The review of the current treatment plan progress stated "(patient) has been going to welfare and doing what she needs to rectify her situation." The Treatment Plan Update documented on January 19, 2012, included documentation on a financial goal. On January 24, 2012, a "Treatment Contract" identified improvement areas of "financial and behavioral." The agreement was in effect for the next 30 days. The "Administrative Withdrawal from Treatment" on February 8, 2012, indicated "client cannot afford treatment." An order for "administrative withdrawal from treatment" was signed by the narcotic treatment physician on February 8, 2012.The discharge summary dated 3/3/2012 documented "(Patient) was unable to pay for treatment and was placed on an administrative detox. (Patient) worked with counselor and clinical staff regarding this decision and was educated about detox and aftercare." The findings were reviewed with the Project Director, Facility Director and Clinical Supervisor and not disputed.
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Plan of Correction
One supervisor is assigned the responsiblity for reviewing all discharge records. The supervisor overseeing these records will see that no patient is D/C due to lack of funding. The only reasons are threatening to commit acts of physical violence in or around the program,a patient possesses a controlled substance wihout a Rx, sold or distributed controlled substance or has been absent from the MM treatment program for 3 consecutive days or longer without cause. Read copy of Patient termination 715.21. Executive Director will monitor throughout the year for compliance in this area. |
715.22(b) LICENSURE Patient grievance procedures
(b) The procedure shall permit aggrieved patients a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director. If the grievance is filed against the narcotic treatment program director, the review of the case shall be conducted by either a multi-representative group of the narcotic treatment program or a subcommittee of the governing body instituted for the express purposes of grievance adjudication.
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Observations
Based on the review of administrative documentation, the facility failed to follow their policy and procedure to ensure that all patients that have submitted a grievance had an opportunity to be heard. The findings include:The facility's policy and procedure manual was reviewed on March 5, 2012. Administrative documentation that included the review of grievances submitted was reviewed on March 6, 2012. According to the facility's policy and procedures, "Once a grievance is filed appropriate staff will meet with the aggrieved party within three days of the grievance. Once the aggrieved party has been heard and had access to information or persons involved and a chance to submit rebuttal, the program director will render adjudication within three working days." Based on documented grievances submitted and staff interview, the facility failed to follow their policy and procedure. There were documented grievances in patient records # 27 and 29 that failed to show documentation that the facility followed their policy.Patient # 27 filed a grievance on March 1, 2012. There was no documentation that indicated that facility staff met with the patient. The facility failed to follow their policy by not meeting with the aggrieved patient within three days following the submission of the grievance.Patient # 29 filed a grievance on June 13, 2011. There was no documentation that indicated that facility staff met with the patient. The facility failed to follow their policy by not meeting with the aggrieved patient within three days following the submission of the grievance.This finding was reviewed with the facility director and was not disputed.
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Plan of Correction
A new grievance form was developed that will require additional information and multiple signatures. One signature will be the Executive Director's signature. The Program director will indicate that the response was and is appropriate. The Grievance binder will be reviewed quarterly by the executive team. |
715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on the review of patient records, the narcotic treatment program failed to complete an initial intake physical examination in one of fifteen records.The findings include: Twenty-six patient records were reviewed on March 5-7, 2012. The narcotic treatment physician failed to document an initial intake physical exam in patient record # 13.Patient #13 was admitted on April 27, 2011. The narcotic treatment physician failed to document a physical evaluation of this patient. The narcotic treatment physician reviewed a physical that was completed on March 20, 2011 by another treatment program. This finding was reviewed with the project director and was not disputed.
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Plan of Correction
All new patients are required and must have an initial intake physical exam. The SOAR physician is responsible for doing the intake physical exam. The Medical Director and/or Clinical Director will be responsible to check this during chart audits and/or supervision with the Medical Doctor.
The Administrative Coordinator of the Chart Room will check the charts for the initial intake physical exam and relay a message to the Medical Director and Executive Director if the intake physical exam was not in the patients chart. A directive from the Executive Director will be sent to the Medical Doctor on this issue. |
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 physical examination by the narcotic treatment physician in two of nine patient records. Additionally, one annual physical examination was completed late. The findings include:Twenty-six patient records were reviewed on March 5-7, 2012. Annual physical examinations by the narcotic treatment physician were required in nine patient records. The narcotic treatment program failed to document the results of the annual physical by the narcotic treatment physician in patient records # 3 and 8. The annual physical examination in patient record #10 was documented late.Patient # 3 was admitted on May 14, 2010. The annual physical examination was due by May 14, 2011. The annual physical examination was not documented in the patient record as of the date of the inspection. Patient # 8 was admitted on June 10, 2010. The annual physical examination was due by June 10, 2011. The annual physical examination was not documented in the patient record as of the date of the inspection.Patient # 10 was admitted on June 25, 2009. The annual physical examination for 2010 was conducted on September 10, 2010. The annual physical examination for 2011 should have been completed by September 10, 2011. The annual physical examination was documented late on October 3, 2011.
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Plan of Correction
A Excel spread sheet will be generated to remind the doctor of the annual physical is due and the Medical Director and/or Clinical Director will be responsible to check this monthly for compliance. |
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 all required laboratory tests as part of the admission process in three of twelve patient records reviewed. The findings include:Twenty-six patient records were reviewed March 5-7, 2012. Twelve patient records were reviewed for completed laboratory tests as part of the admission process, specifically a tuberculosis Mantoux test (PPD). Patient records # 12, 24, and 25 did not have documentation of tuberculosis Mantoux test having been administered as part of the admission process.An interview with the Project Director and Facility Director did not dispute this finding.
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Plan of Correction
Laboratory test were deficient for TB test (tuberculosis Mantoux test) PPD.
The intake coordinator will be responsible to check all transfer patients for the PPD test. If a PPD was not done prior to admission the SOAR Physician, Clinical Director, Nursing Staff, and Clinical Supervisors will be notified by e-mail. A log book of the e-mails will be in the intake coordinators office. It is the Nurses responsibility to see the PPD is done and read according to protocol. The Clinical Director will be responsible to assure that the PPD's are done and recorded. It is the clinical supervisors responaibility to see the PPD is documented in the patient's chart via weekly chart checks. This will be effective 3/19/2012.
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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 eight of eight patient records reviewed. The findings included:Twenty-six patient records were reviewed March 5-7, 2012. Eight patient records required documentation of an annual clinical review. Three were not documented and five failed to be signed and dated by the medical director. Additionally, the annual evaluations that were documented failed to address all required components. The annual evaluations did not address the patient's emotional health and family and community support, as required. The facility failed to document an annual evaluation in patient records # 7, 8 and 21. Patient records # 3, 4, 10, 11, and 22 had an annual evaluation documented; however, the annual evaluations were signed by the narcotic treatment physician and not the medical director, as required by the regulation. Additionally, patient records # 3, 4, 10, 11, and 22, the annual evaluations did not address the patient's emotional health and family and community support. The findings were confirmed by the facility director and were not disputed.
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Plan of Correction
A training on the new Annual Clinical Review Form was done on 3/20/2012 at the staff meeting. Soar was deficient in reporting emotional health and family and community support; these areas were addressed in the new form. The signature section has a section listed as the Medical Director(only)so it is not signed by the SOAR physician. A new form was designed to be more comprehensive and will be in effect April 1, 2012. A Excel spread sheet will be designed to capture when a patient is due for the annual review by 4/1/2012. The Clinical Director and/or clinical Supervisors will be responsible to assure that the reviews are being done during the chart audits and using the spread sheet. |
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 the review of administrative documentation, the facility failed to provide documentation of incident report that involved a drug related hospitalization to the Department.The findings include:Administrative documentation that included the unusual incident reports was reviewed March 6, 2012. The facility had documentation of an incident that identified patient # 15 being transported to the hospital due to impairment. This unusual incident was not reported to the Department as required. This was discussed with facility staff who acknowledged it was not sent.
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Plan of Correction
SOAR Protocol for Incident Reports.A copy of 715.28 with emphasis on(c) #1 to #5 was given to all clinical staff and noted that the incident report must be submitted in 48 hours to the State.
A mini training was done 3/9/12 with the clinical team providing information on incident reporting to the State and CBH. A copy of the report is to be sent to the proper authorities, as well as be included in the patients chart. It is also to be noted in the progress notes including a follow up on the patients progress from the hospital for re-admission to SOAR in situations where a patient was admitted to a hospital. The clinical Supervisors are responsible to see the incident reports are done and followed up through chart audits. The staff person filling out the incident report is responsible to notify both supervisors and the File room coordinator of the incident so they can be a back up check for compliance. |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on the review of patient records, the facility failed to ensure that verbal orders were signed off by the prescribing physician within twenty-four hours in one of one record reviewed.The findings include:Twenty-six patient records were reviewed on March 5-7, 2012. One patient record had verbal orders documented that failed to have the prescribing physician sign off on the order within twenty-four hours. Patient # 4's record included a verbal order from the medical director on August 15, 2011. The doctor that signed off on the verbal order on August 16, 2011 was not the prescribing doctor. This finding was confirmed by the project director and was not disputed.
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Plan of Correction
The Medical Director, and other physicians, as well as the nurses were notified of the deficiency. All virbal doctors order are to be signed within 24 hours. The doctor who wrote the orders must be the one signing off on the order. The clinical Director will be responsible to see this is done. The nursing staff is responsible to bring this to the attention of the Clinical Director when this is about to occure, not after the occurance happened. Nursing documentation will be monitored by the Clinical Director for compliance. |