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 July 28-30, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Parkside Recovery 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 9/1/2009.
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Plan of Correction
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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
Based on the review of patient records, the facility failed to ensure the physician document his rationale for permitting take-home medication in one of one patient record.
The findings include:
Sixteen patient records were reviewed on July 28-30, 2009. One record was reviewed for documentation of the patient's take-home medication approval. Patient record # 8 was awarded three weekly take-home medication bottles per week on July 15, 2009 without the physician documenting his rationale for granting take-home doses.
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Plan of Correction
The Medical Director and Program Director will work together to provide oversight with the programs compliance to regulation 715.16 (a)(3).The Medical Director will re- train and supervise the program physician on how to document rationale for permitting take-home medication in the patient record. This training will take place by 9/28/09 and the program will utilize the charts cited in this deficiency and regulation 715.16 (a)(3)as tools for the training.
The Medical Director will be responsible for documenting the program physician's progress with documenting his rationale for permitting take-home medication in the patient record during their supervision sessions.
The Program Director will be responsible for working with the NHS Program Evaluation Unit thereafter on a monthly basis to conduct audits of client records in order to evaluate the programs compliance to regulation 715.16 (a)(3).
The program will be in full compliance of regulation 715.16 (a)(3).by 9/28/09
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715.17(c)(3)(i-v) 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:
(3) Inspection of storage areas. A narcotic treatment program shall inspect all drug storage areas and the dispensing station at least quarterly to ensure that the areas are maintained in compliance with Federal, State and local laws and regulations. A narcotic treatment program shall develop and implement written policies and procedures regarding who performs the inspections, how often, and in what manner the inspections are to be documented. The policies and procedures shall include the following:
(i) Disinfectants and drugs for external use shall be stored separately from oral and injectable drugs.
(ii) Drugs requiring special conditions for storage to insure stability shall be properly stored.
(iii) Outdated and contaminated drugs shall be removed and destroyed according to Federal and State regulations.
(iv) Administration of controlled substances shall be documented.
(v) Controlled substances and other abusable drugs shall be stored in accordance with Federal and State regulations.
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Observations
Based on a review of the policy and procedure manual, staff interview and reviewing other administrative documentation, the facility failed to ensure the inspection of the storage areas according to required time frames or according to the programs policy and procedure documentation.
The findings include:
The policy and procedure manual was reviewed on July 28 and 29, 2009. The program's policy was to conduct monthly inspections of the medication storage areas.
The binder containing documentation of storage area inspections was reviewed on July 30, 2009. The binder demonstrated the last storage area inspection was conducted July 1, 2008.
An interview with the nurse manager was conducted on July 30, 2009 at which time it was acknowledged the inspections have not been conducted for the past 12 months as required..
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Plan of Correction
The Medical and Program Directors will work together to provide oversight with the programs compliance of regulation 715.17 (c)(3)(i-iv).
The Medical Director will re-train and supervise the Nursing Manager on the requirements for conducting and documenting the inspection of the storage areas according to the time frames indicated in the program policy and procedure manual.
The Program Director will be responsible for providing follow-up of the Nursing Manager with the scheduling of monthly storage inspections in the Microsoft Outlook Calendar scheduling feature. The nursing manager will use this feature to as a reminder to conduct monthly inspections of the storage area.
This training will take place by 9/28/09 and the program will utilize the charts cited in this deficiency and regulation 715.17 (c)(3)(i-iv) as tools for the training.
The program will be in full compliance of regulation 715.17 (c)(3) (i-iv)by 9/28/09.
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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 transfer the required information when a patient was transferred in six of six patient records.
The findings include:
Sixteen patient records were reviewed July 28-30, 2009. Six patient records required the specific information be transferred to the receiving facility. Patient records # 2, 3, 4, 5, 6 and 7 did not document that all of the required information was transferred to the receiving facilities.
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Plan of Correction
The Program Director will provide oversight with compliance to regulation 715. 20 (1) by working with the NHS/Training Department to re- train clinical staff on the clinic to clinic transfer process and the importance of forwarding the required information from the patient record to the transferring facility. This training will take place on 9/14/09. The program will utilize the charts cited in this deficiency and regulation 715. 20 (1) as tools for the training.
The Clinical Supervisor will be responsible for reviewing the patient record to make confrim that the proper documentation is provided as needed.
The program will be in full compliance of regulation 715. 20 (1) by 9/14/09
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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 administrative documentation, the facility failed to restrict the reasons for involuntary termination to those reasons allowed by regulation.
The findings include:
The patient handbook was reviewed on July 29, 2009. The handbook contained documentation to the patients that they may be discharged involuntarily for having weapons onsite and also for having other methadone onsite.
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Plan of Correction
The Program Director reviewed and revised the patient handbook on 7/29/09 to restrict the reasons for involuntary termination to those reasons allowed by the regulation.
The documentation to patients stating that they would be discharged involuntarily for having weapons and methadone onsite was removed from the patient handbook and presented to the state reviews on 7/29/09.
The program will is in full compliance of regulation 715. 21 (1)(i-iv). |
715.22(b) LICENSURE Patient grievance procedures
(b) The procedure shall permit aggrieved patients a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director. If the grievance is filed against the narcotic treatment program director, the review of the case shall be conducted by either a multi-representative group of the narcotic treatment program or a subcommittee of the governing body instituted for the express purposes of grievance adjudication.
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Observations
Based on the review of administrative documentation, the facility failed to ensure a full and fair opportunity for the patients to have their grievances heard for one of three months of grievances reviewed.
The findings include:
The grievance logs for February, March and May 2009 were reviewed on July 28-29, 2009. The grievances filed during the month of March 2009 in particular were not addressed according to procedure or regulation. They were not addressed until July 2009, by which time the patients no longer were invested in pursuing the grievance initiated and the resolution "patient no longer interested" or "resolved" was documented.
There was no indication the program director provided a review of any of the grievances reviewed.
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Plan of Correction
The Program Director will provide oversight with the programs compliance of regulation 715.22(b) by reviewing agency/state procedures and regulations related to this regulation with members of the Consumer Satisfaction Subcommittee.
Staff will be re-trained on those procedures and regulations as they relate to addressing patient grievances to ensure that patients get a full and fair opportunity to have their grievances heard in a timely manner by the program director when needed. The training will be conducted on 9/14/09.The program will utilize the charts cited in this deficiency and regulation 715. 22(b) as tools for the training.
Program Director will be responsible for weekly follow-up with Clinical Supervisor.
The Clinical Supervisor will be responsible for weekly follow-up with the Chairperson of the Consumer Satisfaction Subcommittee to review all patient grievances and ensure that they are forwarded to the program director for review.
The program will be in full compliance with standard 715.22(b) on 9/14/09.
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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 ensure an annual physical examination was completed in four of five patient records.
The findings include:
Sixteen patient records were reviewed July 28-30, 2009. Five records required an annual physical examination by the program. One was completed almost two months late and three had not been done.
Patient record # 8 was admitted May 2007. The annual physical exam was not completed until July 15, 2009.
Patient record # 14 was admitted on 6-4-08 and had not had an annual physical examination at the time of the inspection.
Patient record # 15 was admitted on 7-10-08 and had not had an annual physical examination at the time of the inspection.
Patient record # 16 was admitted on 4-16-07 and had not had an annual physical examination since 4-17-08, more than 3 months overdue.
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Plan of Correction
The Medical and Program Directors will work together to provide oversight with the programs compliance of regulation 715.23 (b)(5).The Medical Director will re-train and supervise the Nursing Manager on the procedures for scheduling annual physical examinations according to the program policy and procedure manual.
The Program Director will be responsible for providing follow-up of the Nursing Manager with the scheduling of annual physical examinations
This training will take place by 9/28/09 and the program will utilize the charts cited in this deficiency and regulation 715.23 (b)(5) as tools for the training.
The program will be in full compliance of regulation 715.23 (b)(5)by 9/28/09
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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 consistently document case consultations in two of four patient records.
The findings include:
Sixteen patient records were reviewed on July 28-30, 2009. Four records were reviewed for compliance to case consultation regulations.
Patient record # 1 was admitted 12-29-08. The last case consultation was completed 3-29-09.
Patient record # 6 had a documented meeting on 3-27-09 with an outside funding source and entitled it as a quarterly case consultation.
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Plan of Correction
The Program Director will provide oversight with the facility's compliance of regulation 715.23(b)(14) by working with the NHS Training Coordinator and the Clinical Supervisor to provide a staff with a training on clinical documentation on 9/14/09. The training will educate clinical staff on the importance of completing and documenting the case consultations in the patient record in a timely manner. The program will utilize the charts cited in this deficiency and regulation 715.23(b)(14) as tools for the training.
The Clinical Supervisor will be responsible for the monitoring, reviewing and documenting of all case consultations that are due on a weekly basis using the existing documentation monitoring tools during weekly clinical supervision with the counselor of record.
The program will be in full compliance with standard 715.23(b)(14) on 9/14/09.
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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
Based on the review of patient records, the narcotic treatment program failed to document evaluative psychosocial assessments in four of six patient records.
The findings include:
Sixteen patient records were reviewed on July 28-30, 2009. Psychosocial evaluations were reviewed in six patient records. The psychosocial failed to include an evaluative assessment of the patient history obtained by clinical staff that included the counselor's clinical analysis of the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, patient's attitude toward treatment and overall impressions. Instead, the psychosocial evaluations of the patient consisted primarily of the repetition of the history and statements reported by the patient in 4 of 6 patient records reviewed for content, patient records # 10, 11, 12 and 13.
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Plan of Correction
The Program Director will provide oversight with the facility's compliance of regulation 715.23(b)(15) by working with the NHS Training Coordinator and the Clinical Supervisor to provide a clinical documentation staff training on formulating, completing and documenting an evaluative psychosocial assessment on 9/14/09. The program will utilize the charts cited in this deficiency and regulation as tools for the training.
The Clinical Supervisor will be responsible for reviewing all psychosocial assessments that are due each week during the counselor's supervision session in order to assess the evaluative content of the psychosocial assessment and make recommendation for correction/improvements when needed.
The program will be in full compliance with standard 715.23(b)(15) on 9/14/09.
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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 review of patient records, the facility failed to ensure that all annual evaluations were completed as required in three of four patient records.
The findings include:
Sixteen patient records were reviewed on July 28-30, 2009. Four patient records were reviewed for annual evaluations.
Patient record # 8 had an annual evaluation due by 5-09, but was not completed until 7-8-09.
Patient record # 14 was due to have an annual evaluation by 6-4-09, but had not been done upon the inspection.
Patient record # 16 was due for an annual evaluation by 4-18-09, but it had not been completed at the time of the inspection.
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Plan of Correction
The Program Director will provide oversight with the facility's compliance of regulation 715.23(c)(1-7) by working with the NHS Training Coordinator and the Clinical Supervisor to provide a staff training on completing and documenting annual evaluations as a requirement of the patient record on 9/14/09. The program will utilize the charts cited in this deficiency and regulation as tools for the training.
The Clinical Supervisor will then utilize the weekly counselor supervision session to review, correct, and document the completion of the patient's annual evaluation for the clinical record . The document will be signed by the client, counselor, program physician and clinical supervisor. It will be noted on the supervisors TPU sheet and forwarded to the medical records department to be filed in the patient record.
The Program Director will work the NHS Program Evaluation Unit on a monthly basis to conduct audits of the patient records in order to evaluate the programs compliance to regulation 715.23(c)(1-7)
The program will be in full compliance with standard 715.23(c)(1-7)on 9/14/09.
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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, the facility failed to document the progress or lack of progress in achieving the goal statements from the prior treatment plan in four of five patient records.
The findings include:
Sixteen patient records were reviewed on July 28-30, 2009. Five patient records were reviewed for treatment plan review.
Patient records # 1 and 7 contained general patient progress statements and did not review the progress (or lack of) in achieving the stated goals.
Patient record # 12 was due for a treatment plan review by 7-8-09, but it was not completed at the time of the inspection.
Patient record # 4 was missing a review update for 10-08. There was a review in August 2008 and another in December 2008, but none in October 2008.
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Plan of Correction
The Program Director will provide oversight with the facility's compliance of regulation 715.23(d)(2) by working with the NHS Training Coordinator and the Clinical Supervisor to provide a clinical documentation training for staff on documenting the status of goal achievements for patients in the patient record. The training will be held on 9/14/09.The program will utilize the charts cited in this deficiency and regulation as tools for the training.
The Clinical Supervisor will then utilize the weekly counselor supervision session to review and document the counselor's progress with documenting the patient's status of goal achievements on the treatment plan update over the next 12 months.
The Program Director will work the NHS Program Evaluation Unit on a monthly basis to conduct audits of the patient records in order to evaluate the programs compliance to regulation 715.23(d)(2).
The program will be in full compliance with standard 715.23(d)(2) on 9/14/09.
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