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 31- August 2, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Soar Corporation Chester 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(e) LICENSURE Intake
(e) A narcotic treatment program shall secure a personal history from the patient within the first week of admission. The personal history shall be made a part of the patient record.
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Observations
Based on a review of patient records, the facility failed to provide a personal history that was completed within the first week of admission in four of five patient records.
The findings include:
Twenty-four patient records were reviewed on July 31- August 2, 2012. Five patient records were reviewed for compliance with the facility policy and this regulation. The facility policy indicated that the personal history was to be completed within 30 days of admission. Additionally, the regulation requires that a personal history is to be obtained from the patient within the first week of admission. The record review revealed that patient records #1, 2, and 11 contained personal histories but the documentation was not signed and dated, making it impossible to determine if the histories were completed in the applicable time frame.
This is a repeat citation from the January 31- February 1, 2012 licensing inspection.
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Plan of Correction
Correction-----The clinical biopsychosocial form will be modified by the Program Director to include more detail on the personal history including the employment, and treatment history. The form will be modified to ensure that all appropriate signature lines are included. The corrections to the biopyschosoical form will be completed within 30 days. Initial personal history will now be collected during the initial intake process by the intake worker. the intake biopsychosocial focusing on personal history is now been made part of the intake package by the program director and is currently being used by on new admissions. Program director has started reviewing completed intakes on the same day it is done to ensure personal history is completed at admission, that all signatures are in place and completed as part of the intake process. Program director and admin assist to audit new admissions within 7 days of admission, to monitor and ensure all intake and personal history paperwork in complete, and signed by staff and pir's. Incomplete paperwork will be returned to the counselor for correction by the program director the same day it is found |
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 ensure that an informed and voluntary consent to release information was obtained in five of twelve patient records reviewed. The facility exceeded 4 Pa. Code, Subsection 255.5(b) in one of twelve records reviewed.
The findings included:
Twenty-four patient records were reviewed July 31- August 2, 2012. Twelve records were reviewed as they pertained to release of information documentation. The facility failed to ensure that an informed and voluntary consent to release information was obtained in five patient records reviewed, # 3, 12, 17, 22, and 23 and patient record # 2 exceeded exceeded 4 Pa. Code, Subsection 255.5(b).
A review of patient record # 2 revealed a consent to release information to a human service agency, signed on May 28, 2012, that exceeded 4 Pa. Code, Subsection 255.5(b). The consent allowed for the release of , "what I am doing at Soar and all files." The form did not indicate what the purpose was for the release.
A review of patient record #3 revealed information was released to a funding source on May 23, 2012. A consent to release information was signed on May 28, 2012 but a review of the record indicated information was provided to the funding entity prior to the signed consent.
A review of patient record #12 revealed information was released to a funding source on May 23, 2012. A review of the record indicated information was provided to the funding entity prior to the signed consent.
A review of patient record #17 revealed information was released to a funding source on May 23, 2012. A consent to release information was signed on May 28, 2012 but a review of the record indicated information was provided to the funding entity prior to the signed consent.
A review of patient record #22 revealed information was released to a funding source on May 23, 2012. A consent to release information was signed on May 29, 2012 but a review of the record indicated information was provided to the funding entity prior to the signed consent.
A review of patient record #23 revealed information was released to a funding source on May 23, 2012. A review of the record indicated information was provided to the funding entity prior to the signed
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Plan of Correction
Program Director to develop a new intake package which includes all of the new ROI's and forms within 30 days. Intake Coordinator and staff start to use this new intake package within 30 days. All Roi's for funding sources will be signed on admission. At Admission, Program Director will review the completed intake paperwork including the ROI's. Incomplete, missing or inappropriate ROI's completed at intake for funding sources and others will be identified by the Program Director. Program Director will instruct the intake worker to correct the issue the identified while the PIR is still present. Past intake, the Program Director and Admin assist will complete 15 chart audits to a month ensure ROI's are updated and information to be relaeased is appropriate. Any issues identified will be corrected by the counselor assigned. Program Director will provide education through supervision about the identified issue with the release. Corrections identified will be completed by the cousnelor in 1 week. Program Director to complete a formal training on the 255.5 regulations for confidentiality within the next 30 days. Program director to create Specific ROI's for Human service providers such as DHS stating information allowed to be released. Counselor's will use these new ROI's, and implementation of these ROI's will be within 30 days |
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, the facility failed to ensure monthly random urine drug screens were conducted in two of twenty-two patient records.
The findings include:
Twenty-four patient records were reviewed July 31- August 2, 2012. Twenty-two patient records were reviewed for monthly urine drug screen results. The facility failed to document random monthly urine drug screens in patient records # 16 and 24.
Patient # 16 was missing urine drug screens for February and March of 2012.
Patient # 24 was missing a urine drug screen for July 2012.
These findings were confirmed by the Acting Program Director and was not disputed.
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Plan of Correction
Lead Nurse will reset UDS schedule in the tower computer system for all pir's within the next 2 weeks to ensure all pir's are programmed in the system for a screen. Director of nursing will monitor this action to ensure completion. Weekend nurses will start to collect UDS on the weekend for the take home pir's that present on the weekend. Weekend collection to start within the next 2 weeks. Lead nurse and Director of Nursing to monitor the scheduled UDS and comleted UDS to ensure weekend staff completed and lack of completion will be addressed by the Lead Nurse. Program Director, Lead Nurse and Director of Nursing will monitor and generate UDS reports from tower at the beginning of the 3rd week of the month. All Pir's who have not completed at least one screen due to missing or postponing a scheduled screen will again be scheduled, placed on hold and will complete a screen by the end of the 4th week of the month. Program Director, Lead Nurse and Director of Nursing will review the monthly UDS report at the close of the month to ensure all uds screens have been completed. |
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
Based on a review of patient records the facility failed to have the narcotic treatment physician review the dosage levels at least twice a year, with each review occurring at least 2 months apart. The narcotic treatment program failed to document the physician's dosage review in four of fourteen patient records.
Findings:
Twenty-four patient records were reviewed on July 31-August 2, 2012. Fourteen patient records were reviewed for the dosage levels to be evaluated by the narcotic treatment physician at least twice a year and at least two months apart. The facility failed to document the physician's dosage review in patient records # 15, 20, 21, and 22.
Patient record #15 revealed the narcotic treatment physician conducted a dosage review on February 2, 2011. This was the only dose review documented in the patient record for 2011.
Patient record #20 revealed the narcotic treatment physician conducted a dosage review on February 14, 2011. This was the only dose review documented in the patient record for 2011.
Patient record #21 revealed the narcotic treatment physician conducted a dosage review on September 15, 2011. This was the only dose review documented in the patient record for 2011.
Patient record #22 revealed the narcotic treatment physician conducted a dosage review on March 1, 2011. This was the only dose review documented in the patient record for 2011.
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Plan of Correction
New spreadsheet and tracking system to be developed by the Program director within 30 days focused on establishing due date for bi-annual reviews and the annual physical. Spread sheet to be updated by Admin Assistant, showing appointments kept, missed or rescheduled. Admin assistant will identify need for appointment and set appointment in Tower for the MD on a weekly basis. Md to complete med review, document it and print note for the chart. Program Director to review spreadsheet and appointments weekly to ensure new tracking system is being used. Chart audits monthly by lead nurse, and program director to check for medical notes in the charts |
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 documented in the patient record the rationale for granting take home medication in two of seven patient records.
The findings include:
Twenty- four patient records were reviewed on July 31-August 2, 2012. Seven records were reviewed for take home medication documentation. Patient records # 21 and 22 did include documenation of the physician's rationale for granting the take home medication.
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Plan of Correction
Program Director shall complete Training with the MD within 30 days on the MD note for the take home, focusing on adding additional content and rationale for the t.h. approval. Program Director shall also review and train MD on the appropriate ways to print his notes to ensure they are placed in the chart within the next 30 days. MD to cease and verbal order granting t.h. to the nursing staff. MD to complete med review appointment for t.h. removal, and generate med note as such. Lead Nurse and Program Director to complete audits on the medical portion of the chart to monitor |
715.16(c)(2)(i-iv) LICENSURE Take-home previliges
(c) A narcotic treatment program shall require a patient to come to the narcotic treatment program for observation daily or at least 6 days a week for comprehensive maintenance treatment, unless a patient is permitted to receive take-home medication as follows:
(2) A narcotic treatment program may permit a patient to reduce attendance at the narcotic treatment program for observation to two times weekly and receive no more than a 3-day take-home supply of medication when in the reasonable clinical judgment of the narcotic treatment physician, which is documented in the patient record:
(i) A patient demonstrates satisfactory adherence to narcotic treatment program rules for at least 2 years.
(ii) A patient demonstrates substantial progress in rehabilitation.
(iii) A patient demonstrates responsibility in handling narcotic drugs.
(iv) A patient demonstrates that rehabilitation progress would improve by decreasing the frequency of attendance for observation.
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Observations
Based on the review of patient records, the facility failed to ensure that the patient met the requirements to have a reduced attendance at the narcotic treatment program and received a 3-day take home supply of medication.
The findings include:
Twenty-four patient records were reviewed on July 31- August 2, 2012. One patient record contained documentation of patient # 6 receiving a three day supply of medication. The patient did not meet eligibility to receive the three day supply of take-home medication.
This finding was reviewed with the Acting Program Director and was not disputed.
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Plan of Correction
Program director will complete a formal training within 30 days on the state guidelines for take home eligibility. All clinical and Medical staff including the MD will be required to attend to be educated on requirements. Program Director will develop a handout that states requirements for take homes and this will be given to all staff within 2 weeks. Program Director to meet with MD and provide education on filing exceptions. This education will be completed within 2 weeks. All future take home request will have to be reviewed by the Program Director prior to the MD review to ensure the request for take homes is accurate and within the guidelines. inapproprite request will be returned to the counselor for correction 1 day after the Program Director revies it. Approprite request will then be given to the MD for their review and medical determination. a training on the guidelines for take homes within 30 days. MD to file a exception request for the cited case within 1 week with assistance from the program director. Program director and lead nurse to run the take home report from tower monthly. a patient's take home schedule will be reviewed by the program director and lead nurse to identify concerns / issues with a t.h. schedule. Concerns noted will then be addressed by the MD within 1 week of being informed |
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 six of twelve patient records reviewed.
The findings include:
Twenty-four patient records were reviewed on July 31-August 2, 2012. Twelve records were reviewed for documentation of an annual physical examination given by the narcotic treatment program that included an annual reevaluation by the narcotic treatment physician. The facility failed to document an annual physical examination which included an annual reevaluation by the physician in patient records # 3, 7, 8, 13, 14, and 15.
Patient # 3 was admitted on April 27, 2011. The patient received a physical examination at the time of admission on April 27, 2010. The record review revealed there was no annual physical examination completed until July 31, 2012. There was no documentation to reconcile any reasons for the facility's failure to complete a patient physical on an annual basis.
Patient # 7 was admitted July 22, 2011. The annual physical exam was not documented as of the date of the inspection.
Patient # 8 was admitted November 13, 2008 and the patient record contained documentation of physical examinations completed by the physician. The record contained physical examinations on November 15, 2010 and July 25, 2012. There was no documentation in the patient record to reconcile any reasons for the facility's failure to complete a patient physical on an annual basis.
Patient # 13 was admitted on November 16, 2010 and the patient record contained documentation of physical examinations completed by the physician. The record contained an initial physical examination on November 5, 2010 and a physical examination on January 3, 2012. There was no documentation to reconcile any reasons for the facility's failure to complete a patient physical on an annual basis.
Patient # 14 was admitted on March 18, 2011 and discharged on May 11, 2012. The facility failed to document an annual physical examination in this patient record.
Patient # 15 was admitted on February 18, 2010. The patient record contained an annual physical examination on April 5, 2012. There was no documentation to reconcile any reasons for the facility's failure to complete a patient physical on an annual basis.
This finding was reviewed with the Acting Program Director and was not disputed.
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Plan of Correction
Program director will develop a spread sheet for the medical department to track annual evaluations and track bi-annual reviews within 30 days. Admin Assistant to set all due dates for evaluations in the spread sheet within 30 days. Admin assistant to check spread sheet weekly and set appointments for evaluations 2 weeks prior to the due date. Program director to monitor appointments being set by cross checking the developed spread sheet to the appointments being set in the tower computer system for the MD. Cross check will be completed every 2 weeks |
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 review of patient records, the facility failed to complete annual evaluations in accordance with the regulations in six of thirteen patient records reviewed.
The findings included:
Twenty-four patient records were reviewed July 31- August 2, 2012. Thirteen patient records required documentation of an annual clinical review. Three evaluations were not documented, one evaluation was late, and two evaluations were done 4-6 months early, specifically records # 4, 7, 8, 15, 20, and 21. Annual evaluations are to be completed within one year of the previous evaluation.
Patient # 4 was admitted on May 17, 2010. The annual evaluation was documented on January 13, 2012 (four months early).
Patient # 7 was admitted on July 22, 2011. The annual evaluation was not documented as of the date of the inspection.
Patient # 8 was admitted on November 13, 2008. The record contained an annual evaluation on November 11, 2011. The next annual evaluation was documented on May 13, 2012 (six months early).
Patient # 15 was admitted December 18, 2010. The record did not include an annual evaluation that was due in December 2011 as of the date of the inspection.
Patient # 20 was admitted February 14, 2011. The record did not include an annual evaluation that was due in February 2012 as of the date of the inspection.
Patient # 21 was admitted on May 9, 2011. The annual evaluation was documented on July 19, 2012, over two months late.
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Plan of Correction
Program Director to complete a Formal Training on the Clinical Annual review with all counselors within the next 30 days. Training will include, time periods of completion, Content review of each subsections of the annual form, and the appropriate signatures needed for the form. Training and review will also focus on the completion of the ¼ case conference review for all pir's under 1 year. Program Director will monitor the completion of the reviews by the use of tracking grid for clinical content that will be developed in the next 30 days. |
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 a review of patient records, it was determined that the facility failed to document the patient's progress as it related to the goals identified in the treatment and rehabilitation plan in one of ten patient records. Additionally, three of ten records failed to have the treatment plan updates, as required.
The findings were:
Twenty-four patient records were reviewed on July 31- August 2, 2012. Ten patient records were reviewed for treatment plan updates that included progress as it related to the goals identified in the treatment and rehabilitation plan. Per the facility's policy and procedures, treatment plan updates are required every sixty days. The facility failed to document in the treatment plan update the patient's progress as it related to the the goals identified in the individualized treatment and rehabilitation plan in patient record # 5. The treatment plan update failed to document the progress of previous goals identified in the treatment plan. Additionally, records # 8, 9, and 15 failed to have treatment plan updates documented every sixty days.
Patient # 5 was admitted on August 8, 2011. The record contained a treatment and rehabilitation plan update that was documented on May 10, 2012 and July 11, 2012. Both treatment plan updates failed to include progress as it related to the current goals identified on the treatment and rehabilitation plan.
Patient # 8 was admitted November 13, 2008. The record contained a treatment plan update documented on April 13, 2012. According to the regulation and the facility's policy, the next treatment plan was due by June 13, 2012. As of the date of the inspection the facility had failed to document additional treatment plan updates as required.
Patient # 9 was admitted on August 26, 2010. The record contained a treatment plan update documented on March 13, 2012. According to the regulation and the facility's policy, the next treatment plan was due May 13, 2012. As of the date of the inspection the facility had failed to document additional treatment plan updates as required.
Patient # 15 was admitted December 18, 2010. The record contained a treatment plan update documented on January 13, 2012. According to the regulation and the facility's policy, the next treatment plan was due by March 13, 2012. As of the date of the inspection the facility had failed to document additional treatment plan updates as required.
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Plan of Correction
new treatment plan form will be used in order to meet the dapl regulations. TX plan form will show progress / updates for individual goals. New plan will be introduced to the counselors within 30 days by the Program director. Program director will complete formal training on form within 30days and will complete a formal training on goal setting during this same time period focusing on defining a long term and short term goal. Counselors will also be given a training manual within the next 30 days written by the program director stating a guideline for all clinical forms used. Program director to monitor progress of goal writing through review of treatment plans in weekly inidivudal supervision sessions |