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 May 8-9, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Care LLC dba Miners Medical was found not to be in compliance with the applicable chapters of 4 PA Code and 28 PA Code which pertain to the facility.
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Plan of Correction
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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 the review of patient records, the facility failed to document pre-natal support in two of two patient records reviewed.The findings include:Thirteen patient records were reviewed May 8-9, 2014. Two patient records were reviewed for documentation of prenatal support. Patient # 12 was admitted July 22, 2013. The patient gave birth on November 22, 2013. There was no documentation of prenatal support prior to the delivery in the counseling records at the time of the inspection. Patient # 13 was admitted September 19, 2013. The patient gave birth, but there was no documentation of prenatal support prior to the delivery in the counseling records at the time of the inspection. There was minimal documentation of the patient's pregnancy in the clinical record. This was discussed with the facility director May 9, 2014.
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Plan of Correction
The facility failed to comply with regulation 715.10 ( c ) requiring patient records to reflect the nature of prenatal support. The faility failed to document prenatal support.
The Counselors will be responsible to document prenatal support on every pregnant patient. The Clinical Supervisor and Facility Director will conduct monthly chart reviews on every pregnant patient to ensure prenatal support is being properly addressed.
Counselors will address and document in patient chart whether the patient is keeping prenatal care appointments, healthy behaviors, and will consult with Miner's Medical's Medical Director, Supervisor, and Facility Director of any areas of concern.
Clinical Staff will receive an In-Service training on 5.29.2014 regarding the importance of prenatal care for their pregnant patients, keeping prenatal care appointments, healthy behaviors, consulting with MM Team, and case documentation. |
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 facilty failed to transfer the required patient files in two of two patient records reviewed.The findings include:Thirteen patient records were reviewed May 8-9, 2014. Two patient records required the facility transfer specific patient files to the receiving narcotic treatment program as part of the transfer process. Two patient records did not include documentation of the transfer of files including the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient.Patient # 8 was discharged as a transfer to another narcotic treatment facility February 7, 2014. The specific files documented as being sent to the receiving facility were the history and physical examination, methadone dose and urine drug screen results. The facility failed to forward the patient's admission date, medical and psychosocial summaries, exception requests and the current status of the patient.Patient # 9 was discharged as a transfer to another narcotic treatment facility March 7, 2014. The specific files sent did not include a medical summary or the current status of the patient.This was discussed with the facility director May 8, 2014.
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Plan of Correction
The facility failed to comply with regulation 715.20 (1) regarding the facility failed to transfer the required patient documentations to another Narcotic Treatment Program.
The Facility Director and Clinical Supervisor will ensure that every patient transfer will receive the required information from the patient file.
A Transfer Out Checklist has been developed that includes the required documents were forwarded. Counselor, Clinical Supervisor, Facility Director will sign off on the Transfer Out Checklist form. Counselors received training on 5.19.2014 and began utilizing the Transfer Out Checklist on 5.19.2014. Counselors will retain all fax confirmation forms. |
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 it notified the referring facility of the admission and initial dosing of the patient in one of two patient records reviewed.The findings include:Thirteen patient records were reviewed May 8-9, 2014. Two patient records were reviewed for documentation of notification to the referring facility of the admission and dosing of the referred patient. The facility failed to notify the referring facility in one of two patient records.Patient # 4 was admitted as a transfer in patient February 28, 2014. There was no consent for the referring narcotic treatment program or documentation that the referring facility was notified of the admission and date of first dose. This was discussed with the clinical supervisor who reported they do not notify referring facilities, or if they do, its done as a courtesy only.
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Plan of Correction
The failed to comply with regulation 715.20 (4) in that the facility failed to document that it notified the referring facility of the admission and initial dosing of the patient.
Clinical and Facility Director will conduct monthly chart reviews to ensure that referring NTP are being notified within 7 days of the admission date and initial dosing of the patient.
Clinical staff will receive an In-Service training on 5.22.2014 by the Facility Director and Clinical Supervisor regarding notifying the NTP within 7 days of admission and of the initial dosing. Counselors will document in the patient record accordingly. |
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 restrict the reasons for involuntary termination to those reasons allowed by regulation in one of two patient records reviewed.The findings include:Thirteen patient records were reviewed May 8-9, 2014. Two patient records were reviewed for involuntary discharge. Two patient records were reviewed for documentation of the reasons for involuntary discharge.Patient # 11 was admitted in June of 2012 and given written notice of intent to involuntarily terminate March 6, 2014. The patient was administratively terminated March 22, 2014 for having a financial balance despite the patient having worked to address this. The patient appeared to be given notice for being behind on a payment plan. This patient was on disability and receiving Medicare Part B according to a progress note dated January 28, 2014. This was placed on the patient's treatment plan January 19, 2014, to apply for Medicare Part B. The clinical note stated the patient was paying $100.00 a month for the Part B and it was active and would cover his treatment. The note continued to state that the billing department would be notified. The notice patient signed on March 6, 2014 stated patient would be subjected to detoxification for failure to attend daily groups "as directed on February 21, 2014." The patient's treatment plan only stated patient was to attend group 1.5 hours a month. A case consultation was dated March 19, 2014, but there was no documentation of the patient's group schedule changing from what was documented on the treatment plan. Additional documentation in the patient record revealed the patient requested a voluntary detoxification on March 5, 2014 for financial reasons. Then on March 11, 2014, another order was documented for a 14 day administrative detoxification. There was no documentation of why this occurred. This was discussed with administrative staff May 9, 2014.
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Plan of Correction
The facility failed to comply with regulation 715.21 (1) (i-iv) in that the facility failed to indicate the reasons for involuntary termination.
Facility Director and Clinical Supervisor will provide an In-Service training on 5.22.2014 regarding the protocol for involuntary termination from Miner's Medical and proper documentation.
Clinical Supervisor and Facility Director will discuss potential involuntary terminations with the Medical Director and entire Treatment Staff.
Clinical Supervsor will ensure proper documentation is in the patient chart via monthly chart reviews. |
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 a review of patient records, the facility failed to document all of the required discharge information in four of four patient records.The findings include:Thirteen patient records were reviewed May 8-9, 2014. Four patient records were required to include documentation of complete discharge summaries. Patient # 8 was discharged February 7, 2014. The discharge summary did not include documentation of the reason for admission, what services were offered and the patient's status at discharge.Patient # 9 was discharged March 7, 2014. The discharge summary did not include documentation of the reason for admission, what services were offered and the patient's status at discharge.Patient # 10 was discharged April 2, 2014. The discharge summary did not include documentation of the reason for admission, what services were offered and the patient's status at discharge.Patient # 11 was discharged March 22, 2014. The discharge summary did not include documentation of the reason for admission, what services were offered and the patient's status at discharge.This was discussed with the facility director on May 9, 2014.
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Plan of Correction
The facility failed to comply with regulation 715.23 (b) (23) regarding the discharge summary providing the following information: reason for admission, services offered, and patient status upon discharge.
On 5.15.2014, the Facility Director and Clinical Supervisor provided a Staff training session in the area of writing a comprehensive discharge summary that includes but is not limited to all Department and Facility required information. Training included proper documentation of Discharge Summaries and included: Patient's reason for treatment, services offered, and patient's status upon dischsrge.
Ongoing monitoring and supervision will be provided by the Clinical Supervisor and Facility Director. |
715.29(5) LICENSURE Exceptions
A narcotic treatment program is permitted, at the time of application or any time thereafter, to request an exception from a specific regulation.
(5) If the exception relates to a specific patient, the narcotic treatment program shall maintain documentation of the exception in the patient 's record.
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Observations
Based on a review of patient records, the facility failed to ensure a patient specific exception approved by the Department was documented in one of one patient records reviewed.The findings include:Thirteen patient records were reviewed May 8-9, 2014. One patient record contained documentation the patient has been dosing offsite at a state psychiatric hospital. There was no documentation of a Department approved exception at the time the patient record was reviewed.Patient # 1 was originally admitted for treatment at the facility July 31, 2012. The patient was hospitalized for psychiatric purposes March 17, 2013 and re-admitted to the facility in May 2013. When the patient was re-admitted in May 2013, the patient was actually a resident in a state hospital for severe psychiatric problems. The documentation stated that a Department exception was requested, but there was no documentation in the patient record the Department had approved the exception. There was further documention for April 2014 of another request by the facility for a Department approved exception, but there was no documentation that the exception request was submitted or approved.This was discussed with the facility director and the counselor of record on May 8, 2014. .
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Plan of Correction
The facility failed to comply with regulation 715.29 (5) in that the facility failed to ensure a patient specific exception approved by the Department was documented in the patient record.
Exception was sent to the Department on 5.13.2014 and Miner's Medical received confirmation on 5.14.2014. Exception is approved until 7.1.2014. Primary Counselor and Clinical Supervisor will ensure Exception is sent to the Department timely.
Staff will receive an in-service training on May 29th, 2014 regarding exceptions. Counselors will maintain fax transmittal reports.
Counselors and Clinical Supervisor will review any active exception to make sure they are still current and timely via chart reviews and case consultations. In the future, if there is a need to request an exception to a regulation, Miners Medical will not implement until department approval is received. |