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 April 6-9, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Consortium 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 and a plan of correction is due on May 16, 2009.
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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 and staff interviews, the facility failed to provide sufficient physician service time for the number of patients being served.
The findings include:
The licensed activity capacity was 420 patients. The onsite physician hours were not sufficient to provide at least one hour of services for every ten patients.
On the day of the monitoring inspection, the facility presented the monitoring questionnaire for review and documented that the census was 334 patients. The physician hours recorded on the questionnaire for that week (4/5-4/11/09) were 18.5 hours for the medical director and 8 hours for the narcotic treatment physician, totaling 26.5 hours per week for the 334 recorded patient census. The facility needed a minimum 33.5 hours physician hours to meet the requirement to have one physician hour of service for every ten patients.
Additionally, the facility failed to meet the requirement during the following timeframes.
The week of 3-28-09 to 4-4-09--12 hours of physician time; there were more than 120 patients enrolled in the program during this timeframe.
The week of 3-21-09 to 3-27-09--8 hours of physician time; there were more than 80 patients enrolled in the program during this timeframe.
The week of 3-14-09 to 3-20-09--14.5 hours of physician time; there were more than 145 patients enrolled in the program during this timeframe.
The week of 3-7-09 to 3-13-09--14.5 hours of physician time; there were more than 145 patients enrolled in the program during this timeframe.
The week of 2-28-09 to 3-6-09--no physician hours were provided for review.
The week of 2-21-09 to 2-27-09--no physician hours were provided for review
The week of 2-14-09 to 2-20-09--25.5 hours of physician time; there were more than 255 patients enrolled in the program during this timeframe.
The week of 2-7-09 to 2-13-09--25 hours of physician time; there were more than 250 patients enrolled in the program during this timeframe.
The week of 1-31-09 to 2-6-09--18.5 hours of physician time; there were more than 185 patients enrolled in the program during this timeframe.
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Plan of Correction
Plan of Correction:
Responsible: The Chief Medical Officer, the Medical Director, the Facility Director,and the Nursing Supervisor will schedule physician services at least 1 hour per week onsite for every ten patients.
Time Frame: We will begin this process effective June 1, 2009
Monitoring:
The Chief Medical Officer, the Facility Director, the Nursing Supervisor, and The Medical Director will monitor the program's census weekly to ensure that we are providing narcotic treatment physician services at least 1 hour per week onsite for every ten patients. |
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 previous narcotic treatment facilities for prior treatment history in two of two patient records.
The findings include:
Nineteen patient records were reviewed on April 7-9, 2009. Contact of prior treatment facilities was required in two patient records. Patient # 11 was admitted February 3, 2009. Patient # 12 was admitted November 14, 2008. The facility did not document contact attempts to obtain prior treatment history in patient records # 11 and 12, though both records contained documentation of prior treatment history. Neither patient record contained a signed patient consent to contact the prior narcotic treatment facility.
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Plan of Correction
Responsible: The Facility Director will monitor the intake assessor and will ensure that information is being requested from prior treatment programs at the time of admission.
Time Frame: This process will be effective June 15, 2009.
Monitoring: The intake assessor will ensure when clients are being referred by another narcotic treatment program, the admitting narcotic treatment program, with a patient consent, shall contact the previous facility for the treatment history. The Facility Director will provide training to the assessor to ensure that this process is being followed.
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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
Based on the review of patient records, the facility failed to secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 and 709.28 in six of nine patient records.
The findings include:
Nineteen patient records were reviewed on April 7, 8, 9, 2009. Nine records were reviewed for confidentiality compliance. Six of the nine records did not have properly documented consents to release information.
Record # 12 contained a Health Insurance Portability and Accountability Act (HIPAA) consent which was generalized and did not include the restrictions set by and 4 PA Code 255.5.
Record # 15 contained a consent to release information to the patient's Primary Care Physician, but failed to include what information was to be released. There was also an emergency contact consent to release without identifying the emergency contact.
Record # 16 contained four different consents to release information without specifying what information was to be released.
Record # 17 contained a consent to release that failed to identify what information would be released and the purpose of the disclosure.
Record # 18 contained two consents that failed to include the signature of the witness.
Record # 19 contained two consents to release information that failed to include who was to receive the information, what information was to be released and the purpose of the disclosure.
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Plan of Correction
Responsible: The Facility Director along with Clinical Supervisors will review with clinicians the appropriate way to fill out a consent to release information in both individual and group supervision.
Time Frame: Effective June 15, 2009
Monitoring: The Facility Director along with the Clinical Supervisors will provide ongoing training in our staff meetings to ensure staff are clear how to properly fill out consent to release forms.
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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 physician failed to determine the proper dosage level for one of nineteen patient records.
The findings include:
Nineteen patient records were reviewed on April 7-9, 2009. Nineteen of nineteen patient records required the physician to determine all dosage levels. Patient record # 9 contained documentation of the physician ordering a detoxification schedule for the patient to begin the detoxification process, but the order did not include the dosing schedule for the timeframe of the detoxification.
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Plan of Correction
Responsible: The Chief Medical Director, Facility Director and the Director of Compliance will develop and implement written policies and procedures regarding the medications used by clients. Ensure proper documentation by physicians in the client's chart indicating their prescribing dose.
Time Frame: Effective June 15, 2009th
Monitoring: The Chief Medical Director, Facility Director and the Director of Compliance will ensure appropriate monitoring of physicians and that all Doctors will properly document a client's need for medication increase or decrease in their progress note as well as what the specific medication dose should be. The Facility Director will will provide training with the Medical Director to ensure that the charts have proper documentation.
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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 to transfer all of the required information to the receiving narcotic treatment facility in one of one patient records.
The findings include:
Nineteen patient records were reviewed on April 7-9, 2009. One record, # 8, was required to document all of the required information that was sent to the receiving facility to complete the transfer process. The facility did not document that they sent the admission date, the psychosocial evaluation, the dosage level and the current status of the patient.
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Plan of Correction
Responsible: The Facility Director and Clinical Supervisors will ensure that the clinicians document all required information that was sent to the receiving facility to complete a transfer. The clinician will document that they sent the admission date, the psychosocial evaluation, the dosage level and the current status of the patient.
Time Frame: Effective June 15, 2009
Monitoring: The Clinical Supervisors will monitor client's charts to ensure that the proper transfer information is in the charts. The Facility Director will provide proper training to the clinicians to ensure that they understand the procedure and what needs to be sent.
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715.23(b)(13) LICENSURE Patient records
(b) Each patient file shall include the following information:
(13) Patient record of services.
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Observations
Based on the review of patient records, the facility failed to include a current patient record of services in six of six records reviewed.
The findings include:
Nineteen patient records were reviewed on April 7-9, 2009. Six records were reviewed for patient record of services. Record of services were not current in active patient records # 11, 12, 14, 15, 16 and 19.
Record # 11--the last documented service date was February 27, 2009. There were multiple progress notes since that date contained in the file up to the week prior to the inspection.
Record # 12--the last documented service date was February 27, 2009. There were multiple progress notes since that date contained in the file up to the week prior to the inspection.
Record # 14--the last documented service date was February 27, 2009. There were multiple progress notes since that date contained in the file up to the week prior to the inspection.
Record # 15--the last documented service date was February 27, 2009. There were multiple progress notes since that date contained in the file up to the week prior to the inspection.
Record # 16--the last documented service date was February 27, 2009. There were multiple progress notes since that date contained in the file up to the week prior to the inspection.
Record # 19--the last documented service date was January 29, 2009. There were multiple progress notes since that date contained in the file up to the February 26, 2009. The status of the patient was unknown due to lack of documented information.
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Plan of Correction
Responsible: The Facility Director and Supervisors will provide training to the the clinicians concerning what is required to be in a record of service such as: daate, the name of the provider and the duration of service.
Time Frame: Effective June 15, 2009
Monitoring: Each Supervisor will monitor clients charts to ensure that the proper record of service for each client is in the chart in chronological order. |
715.23(b)(14) LICENSURE Patient records
(b) Each patient file shall include the following information:
(14) Case consultation notes regarding the patient.
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Observations
Based on the review of patient records, the facility failed to complete case consultations in three of six patient records.
The findings include:
Nineteen patient records were reviewed on April 7-9, 2009. Six records were reviewed for case consultations. Records # 2, 12 and 13 did not contain the required case consultations.
Record # 2 was admitted July 1, 2008 and contained two case consultations. They both had the same date, September 22, 2008, and the same verbiage, but different participants were identified on each. There was no record of case consultations since September 22, 2008.
Record # 12 was admitted November 14, 2008 and had a case consultation form completed and dated for February 9, 2009. It was written as if it were a progress note and there were no identified participants. A consultation needed at least two people to be a consultation.
Record # 13 was admitted April 18, 2008. There were no case consultations documented in the record.
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Plan of Correction
Responsible: The Facility Director, Clinical Supervisors will conduct staff trainings on the importance, frequency and content of a case consultation along with them properly being filed in the chart. All charts that have been named in this inspection, the supervisors will meet with the clinician to ensure that the consults are completed and placed in the charts.
Time Frame: Effective June 15, 2009
Monitoring: The Clinical Supervisors will follow-up with clinicians in individual supervision to review client's charts and will discuss with clinicians when case consults are or are not present in the chart. |
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 the review of patient records, the narcotic treatment program failed to document discharge summaries within required timeframe in five of five patient records.
The findings include:
Nineteen patient records were reviewed on April 7-9, 2009. Discharge summaries were required in five patient records. The narcotic treatment program did not document discharge summaries within the required seven days of discharge. The program had a policy of waiting 30 days after the last day treatment is provided before discharging the patient in the event they may return. However, there were certain circumstances when this would not be an option and the discharge summary must be completed in the required seven days.
Patients # 1, 2 and 3 were all discharged because they were deceased. Record # 1- the death was identified as occurring on October 27, 2008; the discharge summary was not completed until November 10, 2008.
Record # 2 - the death was identified as occurring on January 5, 2009 and the discharge summary was not completed until January 27, 2009. Record # 3 - the death was identified as occurring on the weekend of January 16-17, 2009 and the discharge summary was not completed until February 20, 2009.
Patient # 8 was transferred to another treatment clinic in another state November 11, 2008. the discharge summary was completed December 1, 2008.
Patient # 9 was administratively detoxified with the last date of treatment being August 28, 2008. The discharge summary was completed October 1, 2008.
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Plan of Correction
Responsible: The Facility Director and Clinical Supervisors will schedule trainings with clinicians for them to be educated on the importance of a discharge summary, the purpose and the required timeframe for the discharge summary to be completed. The Supervisors will meet with clinicians concerning all charts that were reviewed during this inspection and did not have a discharge summary. Discharge summaries will be completed on these charts.
Time Frame: Effective June 15, 2009
Monitoring: The Clinical Supervisors will meet with clinicians on a weekly basis in supervision to review client charts determine if discharge summaries have been completed on all required charts.
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715.23(d)(2) 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.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Based on the review of patient records and the policy and procedure manual, the narcotic treatment program failed to document treatment plan updates in four of seven patient records.
The findings include:
Nineteen patient records were reviewed on April 7-9, 2009. Treatment plan updates were required in seven patient records. The narcotic treatment program did not document in the treatment plan updates the patient's progress in relationship to the stated goals in patient records #10, 12, 13 and 16.
Record # 10 had not had a treatment plan update since December 31, 2008.
Record # 12, a treatment plan update was due March 25, 2009; it was not completed at the time of the inspection.
Record # 13 was required to have a treatment plan update every 30 days according to program policy and failed to have updates for March 3 and April 3, 2009.
Record # 16 had a document completed that stated it was a treatment plan update, but there was no master treatment plan on which to base the review. It contained a general comment of the patient's overall progress and was not goal related.
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Plan of Correction
Responsible: The Facility Director and Clinical Supervisors will schedule trainings to train staff on the importance of treatment plan updates, how they should be completed, and the required time period in which they should be completed. The Clinical Supervisors will review any charts that were found deficient with clinicians during the inspection and did not have a treatment plan update and will complete the treatment plan update.
Time Frame: Effective June 15, 2009
Monitoring: The Clinical Supervisors will meet with each clinician on a weekly basis and will review client charts to ensure that treatment plans have been completed on correctly and according to the required time period. |
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 and patient records, the facility failed to file a written Unusual Incident Report with the Department within 48 hours.
The findings include:
Administrative documentation that included unusual incident reports was reviewed on April 7, 2009. An incident with the potential for negative community reaction was documented. The report discussed the facility having dosed a person who was not a registered patient with the facility with the medication that was to be dispensed to a registered patient.
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Plan of Correction
Responsible: The Facility Director shall ensure that all Unusual Incident Reports are filed with the Department within 48 hrs. following an unusual incident including: complaints of client abuse, Death or serious injury, Significant disruption of services due to disaster such as a fire, storm, flood or other occurrences, incidents with potential negative community reaction or which the Facility Director believes may lead to community concerns, and drug related hospitalization.
Time Frame: Effective June 15, 2009
Monitoring: The Clinical Supervisors will ensure that the Unusual Incident Reports are written and given to the Facility Director within 48 hrs. for the Facility Director to review and then file the report.
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709.14(b)(4) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(4) Change in activity/discontinuance of an activity.
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Observations
Based on a review of patient records and discussion with facility staff, the facility is providing unlicensed partial hospital services.
The findings include:
Nineteen patient records were reviewed on April 7-9, 2009. Discussions were held with three clinical supervisors, the facility and project directors and the Chief Medical Officer of the project. Documentation of record of services and progress notes reflected two levels of care being referred to as either Outpatient (OP) or Intensive Outpatient (IOP). The required hours of treatment for IOP was documented as 3-three hour groups and 1-one hour individual session per week. 10 hours per week of treatment services was the minimum starting number of hours for partial hospital level of care treatment. Records # 11 and 12 reflected the 10 hour a week IOP form of treatment.
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Plan of Correction
Responsible: The Facility Director along with the Clinical Supervisors will ensure that the IOP program shall run for less than ten hours a week which will be in compliance with IOP required hours and will not exceed IOP required hours.
Time Frame: Effective June 30, 2009
Monitoring: As of June 30, 2009, The Facility Director along with the Clinical Supervisors changed the weekly hours of the IOP program to 9.5. This was done by shortening some of the groups during the course of the week to ensure that the required time was not exceeded. Therefore with total hrs. of grp. as well as the individual sessions, the IOP program is now at 9.5 hrs. a week. |