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 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection January 28, 29 and 30, 2008, JF Kennedy MH/MR Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on February 26, 2008.
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Plan of Correction
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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 random review of 12 patient records, as well as discussion with program staff, the facility failed to complete drug-screening urinalysis at least monthly in three of seven patient records reviewed, specifically patient records # 3, missing March 2007, # 4, missing December 2007 and # 5, missing October 2007. In addition, patients # 3, 4 and 10 had an intake urine drug screen approximately one month prior to admission. Urine drug screens must be current reflecting the patient's status at admission.
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Plan of Correction
Effective March 3, 2008 all patient urine samples will be collected for testing during the first three weeks of each month. The final week of the month will be reserved to sample patients who have been absent or otherwise unavailable. In addition, a current urine drug screen will be collected for all patient transfers at admission. Our Lead Nurse will be responsible for monitoring compliance with this procedure. |
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
Based on the random review of 12 patient records, as well as discussion with program staff, the physician failed to write an order for take home doses in one of three patient records reviewed, # 6.
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Plan of Correction
Our Clinic Physician signed the computer generated methadone order for take home bottles. Effective immediately, the physician will consistently write a manual order on our standard physician order sheet. Our Lead Nurse will monitor patient orders to ensure compliance. |
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
Based on the random review of 12 patient records, as well as discussion with program staff, the facility failed to ensure the physician documented the rationale for permitting take home doses in two of two patient records, specifically # 2 and 7.
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Plan of Correction
Our Take-Home Medication request form has been revised to clearly reflect the physician's rationale for permitting take home doses. The Clinic Director is responsible for ensuring compliance with this procedure. |
715.16(b)(1-8) LICENSURE Take-home privileges
(b) The narcotic treatment physician shall consider the following in determining whether, in exercising reasonable clinical judgment, a patient is responsible in handling narcotic drugs:
(1) Absence of recent abuse of drugs (narcotic or non-narcotic), including alcohol.
(2) Regular narcotic treatment program attendance.
(3) Absence of serious behavioral problems at the narcotic treatment program.
(4) Absence of known recent criminal activity.
(5) Stability of the patient 's home environment and social relationships.
(6) Length of time in comprehensive maintenance treatment.
(7) Assurance that take-home medication can be safely stored within the patient 's home.
(8) Whether the rehabilitative benefit to the patient derived from decreasing the frequency of attendance outweighs the potential risks of drug diversion.
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Observations
Based on the random review of 12 patient records, as well as discussion with program staff, the facility failed to demonstrate the physician considered the 8-points required in order to determine if a patient is responsible to handle narcotic drugs in three of three patient records reviewed, # 2, 6 and 7.
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Plan of Correction
Our phyaician has been provided a revised Take-Home Medication request form which is designed to prevent a recurrence of this problem. The physician's consideration of the patient's ability to be responsible for take home medication will be consistently documented. Our Clinic Supervisor will review and sign each take-home request to ensure 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 random review of 12 patient records, as well as discussion with program staff, the facility failed to obtain confirmation of a patient-reported past positive PPD in one of four patient records reviewed, #1. In addition, patient record #2 was missing documentation of having had a Mantoux test.
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Plan of Correction
The physician has been instructed to promptly obtain medical records that confirm patient-reported past positive PPD. In addition, our physician has been instructed to obtain a PPD result for all patients admitted to our methadone clinic. The Lead Nurse is responsible for working along with the physician to ensure that verification of patient-reported past positive PPD is promptly obtained. The Lead Nurse is responsible for reviewing all physical examinations by the physician to ensure PPD results are in the chart. |
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 random review of 12 patient records, as well as discussion with program staff, the facility failed to complete an annual evaluation in three of four patient records reviewed, # 1, 5 and 7.
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Plan of Correction
All clinical staff have been reminded to consistently complete an annual evaluation on or before the patient's anniversary date of treatment. Staff will receive weekly supervision be the Clinic Director to ensure compliance. |