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 16-18, 2011 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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715.9(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 five of five patient records reviewed.The findings include:Twenty eight patient records were reviewed December 20-22, 2010. Five patient records required contacting the prior narcotic treatment facility for the previous treatment history the patient's reported to have received. Patient records # 1, 3, 8, 23 and 28 contained documentation the patients had received narcotic treatment services previously at other narcotic treatment programs. None of the five patient records reviewed contained documentation of any attempt to obtain the patient's prior treatment history from the previously attended narcotic treatment facilities.
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Plan of Correction
Clinical Supervisor to do inservice training regarding soar policies and state regs regarding obtaining pt previous records from other MAT programs. Clin Sup will monitor weekly in supervision. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on the review of patient records and discussion with facility staff, the facility failed to complete an initial and random drug screening urinalysis at least monthly for six of fifteen patient records.The findings include:Eighteen patient records were reviewed May 16-18, 2011. Fifteen patient records were reviewed for initial and random drug-screening urinalysis. Patient # 5 was admitted March 16, 2011. The first drug-screening documented in the patient record was dated April 12, 2011 and the results were reported April 18, 2011.Patient # 6 was admitted January 27, 2009. A random drug-screening urinalysis was not completed for January 2011. Patient # 7 was admitted December 3, 2009. A random drug-screening urinalysis was not completed for February 2011. Patient # 8 was admitted December 2, 2008. A random drug-screening urinalysis was not completed for February 2011. Patient # 17 was admitted October 23, 2009. A random drug-screening urinalysis was not completed for February 2011. Patient # 18 was admitted December 22, 2008. A random drug-screening urinalysis was not completed for March 2011. The facility director and clinical supervisor reviewed the patient records and the lab results stored in the dosing area and agreed the results were not there.
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Plan of Correction
Director will meet with intake workers and review policies and regs regarding urine testing for intake purposes. Director will talk to computer vendor to insure that system is properly pulling pts every month for a urine. Clin Sup will meet with all counselors and discuss the need to check each pts chart during sessions for the random monthly urine test. Clin Sup will also followup during weekly supervision to make sure that this is being done. Director will follow up quarterly with software vendor/computer to make sure that urines are being asked for every 30 days. |
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 transfer the required patient files in one of one patient record.The findings include:Eighteen patient records were reviewed May 16-18, 2011. One patient record required that the facility transfer specific patient files to the receiving narcotic treatment program as part of the transfer process. Patient # 15 was discharged as a transfer to another narcotic treatment facility March 23, 2011. There was no documentation of the required patient files being transferred to the receiving facility. The consent signed by the patient for the transfer did not include the patient's dose, admission date, medical summary, exceptions and/or current status.
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Plan of Correction
Director to meet with nursing staff and present them with new form that will be used for all pt transfer both incoming and outgoing. Memo issued to all counselors regarding proper way to followup on a transfer to another MAT program. Clin Sup to monitor weekly during supervision. Director will have Nurse Manager monitor transfer charts for compliance by nursing on forms and proper documentation. |
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 two of three patient records.The findings include:Eighteen patient records were reviewed May 16-18, 2011. Three patient records were reviewed for documentation of notification to the referring facility of the admission and dosing of the referred patient. Patient # 5 was referred by another narcotic treatment program March 16, 2011 and there was no documentation of the referring program being notified of the admission and initial dosing of the patient at the time of the inspection review. Patient # 13 was referred by another narcotic treatment program April 13, 2011 and there was no documentation of the referring program being notified of the admission and initial dosing of the patient at the time of the inspection review.
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Plan of Correction
Letter form developed and reviewed with nursing who have been given the responsibility of sending this letter to the referring facility. Mini inservice by director to all nurses on proper way to fill out form and time frame for sending said form to referring facility. Clin Sup to monitor for forms during chart audits and weekly supervision. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on the review of patient records, the facility failed to complete the annual physical with a re-evaluation by the physician in five of seven patient record reviewed. The findings include:Sixteen patient Patient # 6 was admitted January 27, 2009. The annual physical exam due in January 2011 was not completed at the time of the inspection review.Patient # 7 was admitted December 3, 2009. The annual physical exam due in December 2010 was not completed at the time of the inspection review.Patient # 12 was admitted March 15, 2010. The annual physical exam was not completed at the time of the inspection review.Patient # 18 was admitted December 22, 2008. The annual physical exam was completed on January 12, 2011 by the Certified Registered Nurse Practitioner (CRNP), but did not include a re-evaluation by the physician.
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Plan of Correction
Software vendor contacted by Director to place automatic prompt in all pt electronic files that would inform everyone when annual physical due. Requested that Drs be given their own alert when a physical is due. Vendor said this could be done in less than 30 days. Memo given to all counselors regarding their need to make sure that annual physicals for pts on their caseloads are being done in a timely manner. |
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 four of four patient records reviewed. The findings include:Eighteen patient records were reviewed May 16-18, 2011. Four patient records were reviewed for completed laboratory tests as part of the admission process, specifically a tuberculosis Mantoux test (PPD) and serology tests for Syphilis (RPR). Patient # 1 was admitted April 11, 2011. Documentation of the Mantoux test and serology RPR was not in the patient record at the time of the review.Patient # 5 was admitted March 16, 2011. Documentation of the Mantoux tuberculosis test was not in the patient record at the time of the review. The patient's blood was collected for the RPR serology May 10, 2011, well beyond the patient's admission date.Patient # 13 was admitted April 14, 2011. Documentation of the Mantoux tuberculosis test was not in the patient record at the time of the review. Patient # 11 was admitted January 19, 2011. Documentation of the Mantoux test and serology RPR was not in the patient record at the time of the review.
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Plan of Correction
Intake coordinator to give all new pt charts to Clin Sup before they are assigned to a counselor. Clin Sup will then audit chart to ensure that all required paperwork is there for medical tests. Clin Sup will then assign pt to a counselor. Whole process is to be done in less than 72 hrs. Nurse manager and/or Director will monitor for compliance throughout the year. |
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 information in five of five patient records.The findings include:Eighteen patient records were reviewed May 16-18, 2011. Five patient records were required to have discharge summaries. Patient # 14 was admitted August 7, 2008 and discharged December 11, 2010 as a successful completion of treatment. The discharge summary form utilized by the facility did not include the reason(s) that the patient entered treatment, services offered or the status or condition of the patient upon discharge. The response to treatment did not reflect a summary of more than two years of treatment, but the patient's drug use status. In addition, the discharge summary was not signed or dated, therefore compliance to timeframe required for completion could not be determined.Patient # 15 was admitted October 28, 2010 and discharged March 23, 2011 as a transfer. The reason for admission was restricted to patient statement of wanting to have a better life. There were no services offered to the patient during the treatment process documented or the patient's status at discharge. Patient # 16 was admitted August 28, 2008 and discharged April 28, 2011 as a successful completion of treatment. The reason patient entered treatment was not documented.Patient # 17 was admitted October 23, 2009 and discharged March 1, 2011 as non-compliant to treatment. The reason for admission was restricted to patient statement of wanting to have a better life. Only clinical counseling services offered to the patient during the treatment process was documented, while other services the patient received was not included. The patient's status at discharge was not documented in the discharge summary. Patient # 18 was admitted December 22, 2008 and discharged March 15, 2011 as having completed treatment. The reason for admission was restricted to patient statement of wanting to have a better life. Only clinical counseling services offered to the patient during the treatment process was documented, while other services the patient received was not included in the documentation. The patient's status at discharge was not documented in the discharge summary.
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Plan of Correction
Minimum of 2 inservices to be given by Director and/or Clin Sup to all clinical staff regarding proper way to be in complince in these areas. Clin Sup to monitor for compliance both in weekly supervision and chart audits. |