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 October 1-3, 2012 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.
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Plan of Correction
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715.23(a) LICENSURE Patient records
(a) A narcotic treatment program shall maintain patient records in conformance with 42 CFR 2.16 and 2.22 (relating to security for written records; and notice to patients of Federal confidentiality requirements) and State statutes and regulations. A narcotic treatment program shall maintain a complete file on the premises for each present and former patient of the narcotic treatment program for at least 4 years after the patient has completed treatment or treatment has been terminated. Files shall be updated regularly so that the information is current.
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Observations
Based on the review of patient records and discussion with clinical staff, the facility failed to ensure the patient records were complete and updated regularly with current information in eleven of twenty one patient records reviewed.
The findings include:
Twenty one patient records were reviewed October 1-3, 2012. Twenty one patient records were required to include documentation of complete and current information.
Patient records # 5, 20 and 21 did not have current progress notes.
Patient # 5 had died and was discharged April 10. 2012. The last progress note was dated January 4, 2012.
Patient Record # 20 had no progress notes between October 2008 and April 2011.
Patient Record # 21 had no progress note since August 3, 2012.
Patient records # 13, 15, 19 and 21 did not have the required case consultations.
Patient # 12 was admitted February 7, 2012. There were no case consultations in the record at the time of the inspection.
Patient # 15 was admitted April 21, 2011. There was only one case consultation dated July 15, 2012.
Patient # 19 was admitted January 14, 2005. An annual case consultation was to have been completed in January 2012. The only case consultation in the patient record was dated May 21, 2012, four months late.
Patient # 21 was admitted February 26, 2009. The "bi-annual" case consultation dated June 12, 2012 was for his twin brother and not this patient.
Patient records # 15, 19 and 20 did not have the required annual evaluations.
Patient # 15 was admitted April 21, 2011 and discharged August 9, 2012. There was no annual evaluation documented in the patient record at the time of the inspection.
Patient # 19 was admitted January 14, 2005. There was an annual evaluation dated May 21, 2012 that was not signed by the medical director. Patient # 20 was admitted October 2, 2002. The annual evaluation for October 2011 was not in the record. There was an annual evaluation dated May 8, 2012 that was signed by the physician and supervisor on July 3 and 5, 2012, respectively.
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Plan of Correction
Responsible Party(s):
The Clinical Supervisors, Clinical Counseling Staff and Medical Records Staff are responsible for ensuring that patient records are complete and updated regulary with curent patient information.
Timeframe for Completion:
Clinical Counseling Staff will be trained by the Clinical Supervisors and the Facility Director regarding the timelines for completion of documentation as well as the importance of maintaining a complete and updated patient record.
Training will be completed by 11/30/12.
Medical Records staff will recieve training and documented supervision regarding the timelines for filing current documentation in the patient record by 11/30/12.
Records:# 5, 20 and 21 will be reviewed and will have any outstanding progress notes completed and filed in the client record by 11/30/12.
Records 13, 15, 19 and 21 will have case consultations completed by 11/30/12.
Records #15, 19 and 20 will have an annual evaluation completed by 11/30/12.
Monitoring:
The Assistant Facility Director will provide weekly to bi-weekly supervision with the Medical Records Staff to review the status of filing and to ensure that all patient records have complete and current information.
The Clinical Supervisor will provide bi-weekly to monthly supervision with Clinical Counseling Staff to monitor the completion of required documentation and to ensure the smooth transition of the documentation from the Counselor of Record to the Medical Records office.
The Facility Director and the Clinical Supervisors will conduct monthly patient record reviews to ensure that all required documentation is fully completed and filed into the clinical record.
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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 complete case consultations as required in four of eight patient records.
The findings include:
Twenty one patient records were reviewed October 1-3, 2012. Eight patient records were reviewed for case consultations.
Patient records # 13, 15, 19 and 21 did not have the required case consultations. Patient # 12 was admitted February 7, 2012. There were no case consultations in the record at the time of the inspection. Patient # 15 was admitted April 21, 2011. There was only one case consultation dated July 15, 2012. Patient # 19 was admitted January 14, 2005. An annual case consultation was to have been completed in January 2012. The only case consultation in the patient record was dated May 21, 2012, four months late. Patient # 21 was admitted February 26, 2009. The "bi-annual" case consultation dated June 12, 2012 was for his twin brother and not this patient.
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Plan of Correction
Responsible Party(s):
The Clinical Supervisors and Clinical Counseling Staff are responsible for ensuring that case consultations are completed quarterly during the first year of treatment and annually thereafter.
Timeframe for Completion:
Clinical Counseling Staff will be trained by the Clinical Supervisors and the Facility Director regarding the timelines for completion of case consultations.
Training will be completed by 11/30/12.
Records# 13, 15, 19 and 21 will have all required case consultations completed and filed in the patient record by 11/30/12.
Monitoring:
The Clinical Supervisors will provide weekly to bi-weekly supervision with the Clinical Counseling Staff to monitor the completion of case consultations.
The Facility Director and the Clinical Supervisors will conduct monthly patient record reviews to ensure that all required case consultations are completed and filed into the clinical record.
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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 the review of patient records, the facility failed to complete annual evaluations in accordance with the regulations in three of four patient records reviewed.
The findings included:
Twenty one patient records were reviewed October 1-3, 2012. Four patient records were reviewed for annual evaluations.
Patient records # 15, 19 and 20 did not have the required annual evaluations.
Patient # 15 was admitted April 21, 2012 and discharged August 9, 2012. There was no annual evaluation documented in the patient record at the time of the inspection. Patient # 19 was admitted January 14, 2005. There was an annual evaluation dated May 21, 2012 that was not signed by the medical director. Patient # 20 was admitted October 2, 2002. The annual evaluation for October 2011 was not in the record. There was an annual evaluation dated May 8, 2012 that was signed by the physician and supervisor on July 3 and 5, 2012, respectively.
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Plan of Correction
Responsible Party(s):
The Clinical Supervisors, Clinical Counseling Staff and Medical Records Staff are responsible for ensuring that annual evaluations are completed each year.
Timeframe for Completion:
Clinical Counseling Staff will be trained by the Clinical Supervisors and the Facility Director regarding the timelines for completion of of annual evaluations.
Training will be completed by 11/30/12.
Records:# 15,19 and 20 will have completed annual evaluations by 11/30/12.
Monitoring:
The Clinical Supervisor will provide bi-weekly to monthly supervision with Clinical Counseling Staff to monitor the completion of required annual evaluations.
The Facility Director and the Clinical Supervisors will conduct monthly patient record reviews to ensure that all required annual evaluations are fully completed, signed by the Medical Director, and filed into the clinical record.
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