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 August 15, 16 and 17, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Alliance Medical Services, Ensign I was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on September 7, 2007.
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Plan of Correction
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715.9(b)(2) LICENSURE Intake
(b) Exceptions to the requirements in subsection (a) are:
(2) Upon readmitting a patient who has been out of a narcotic treatment program for 6 months or less after a voluntary termination, the narcotic treatment program shall update the information in and review the patient 's file to show current opiate narcotic dependency, but need not conduct a physical examination and applicable laboratory tests. Privileges earned during the previous treatment may be reinstated at the discretion of the narcotic treatment physician.
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Observations
The facility failed to establish current narcotic dependency for patient #9, as they failed to obtain a complete urinalysis prior to patient's readmission.
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Plan of Correction
The facility will routinely require a urine drug screen of previous patients seeking readmission. The prospective patient will not be admitted and dosed until the results establish current dependancy. In certain cases the Medical Director may establish dependancy through other approved methods. The Medical Director is responsible for oversite in this matter with the participation of the Facility Director |
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
The facility failed to contact a previous treatment facility to obtain the patient's treatment history. Specifically, patient #1 had prior narcotic treatment experiences; the facility had releases to request the information but had no record that the information was requested or received.
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Plan of Correction
Staff training will be conducted regarding the necessity of including pertinent information from all previous treatment experience, so far as they can be verified. The Project and Facility directors are responsible for implementing this training, and the Facility director will review charts, as pert of their routine responsibility, to monitor the inclusion of this information.
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715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
The facility failed to revise documentation contained in the patient rights form, specifically to remove references to releasing information to the Bureau of Drug and Alcohol Programs.Based on a review of patient records and written consent to release information forms, it was determined that the facility failed to fully identify the recipient of the information and that entity's or person's relationship to the patient in patient records # 6, 7, 8, and 14.
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Plan of Correction
The facility has revised the patient rights form and removed references to releasing information to BDAP.
Staff training will occur to specify appropriate completion of release forms to include a full identification of the recipient and to delineate the entity's relationship to the patient. The Facility Director and Clinical Supervisor shall provide training and oversight on an ongoing basis.
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715.14(c) LICENSURE Urine testing
(c) A narcotic treatment program shall develop and implement policies and procedures to minimize misidentification of urine specimens and to ensure that the tested specimens can be traced to the donor.
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Observations
The facility failed to provide policy and procedures that addressed the security of the specimen collected. The plan did not provide information regarding the secure storage of the specimen until it is transported to laboratory for analysis.
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Plan of Correction
Policy and procedure will be updated to include an appropriate chain of custody for all urinalysis and lab tests to be secure. The Facility Director will be responsible for compliance.
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715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
The facility failed to document in 20 of 20 patient records reviewed that the physician had conducted biannual reviews of the methadone dose for each patient. Documentation at time of annual physical examination revealed that the certified registered nurse practitioner was conducting the dose review and determining the patient's dose. The physician co-signed the physical examination form without indication that the current dose was reviewed. Staff confirmed it was the facility's intent to conduct a biannual dosage review during the annual physical evaluation.
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Plan of Correction
The AMS Physician will conduct a biannual dosage review. The physician is solely responsible for determining patient dosing level. The Facility Director will monitor compliance for this regulation. The annual physical form will be adjusted to allow for the medical Director's signature and comments regarding the dosage.
The current computer data base system will be updated to alert the Medical Director the a bi-annual dosage review is due.
The Medical Director and the Facility Director are responsible for implementation and ongoing 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
The facility failed to have the physician determine a one time exception for patient #9. Documentation in the patient's record indicated that the certified registered nurse practitioner had authorized the take-home dose without consultation with physician. The certified registered nurse practitioner signed the take-home order on the line where the physician's signature is to be recorded.
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Plan of Correction
The AMS physician will be solely responsible for determining take home dosages in consultation with appropriate staff. Ongoing compliance with this regulation will be the responsibility of the Facility Director.
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715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
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Observations
The facility failed to have physician document his rationale for ordering take home doses. The patient files reviewed contained documentation that was entered by staff with the physician's signature on the reviewed documents. The physician's rationale for ordering take home medications was not recorded.
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Plan of Correction
The AMS physician will be solely responsible for determining take home dosages in consultation with appropriate staff. He will provide the rationale for providing or denying any take home doses to patients.Ongoing compliance with this regulation will be the responsibility of the Facility Director.
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715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
The facility failed to provide the minimum requirement of 2.5 hours of psychotherapy for patient #15 for the months of June and July, 2007.
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Plan of Correction
The facility will provide the minimum requirement for psychotherapy for all patients. Ongoing compliance with this regulation will be the responsibility of the Clinical Supervisor through regular record review and weekly clinical supervision.
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715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
The facility failed to complete a psychosocial evaluation within the facility's established time frames. Specifically, patient #11 was admitted to facility on July 6, 2007 and an evaluation was not documented as of August 17, 2007.
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Plan of Correction
Staff will be trained and directed that all biopsychsocials must be competed within 30 days of admission, and that this process should begin prior to the completion date. In the event that extraordinary events preclude the possibility of completion, those events will be documented in the patient record. The facility director will monitor compliance with this policy.
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715.23(d) 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.
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Observations
The facility failed to provide treatment plans according to facility policies and procedures, patient #11, admitted July 6, 2007, did not have a comprehensive treatment plan as of August 17, 2007.
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Plan of Correction
Staff will be trained and directed that all comprehensive treatment plans must be competed within 30 days of admission, and that this process should begin prior to the completion date. In the event that extraordinary events preclude the possibility of completion, those events will be documented in the patient record. The facility director will monitor compliance with this policy.
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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
The facility failed to notify the Department of incidents as required by regulations. Specifically, facility records documented incidents that the facility failed to submit to the Department such as hospitalization of patients, incidents involving the police, a car accident involving a patient in front of facility, and physically threatening behavior of patients towards staff and other patients.
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Plan of Correction
All incident reports as indicated in the regulation will be faxed to Department offices within 48 hours. Fax verification will be maintained with the report. The Facility Director will be responsible for compliance.
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