INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on September 17, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Asociacion Puertorriquenos en March, Inc. was found not to be in compliance with the applicable chapters of 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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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the project failed to obtain an informed and voluntary consent to release information form from the client for the disclosure of information contained in the client record in three of four records reviewed.
Client #1 was admitted on August 24, 2020 and was still active at the time of the inspection. An informed voluntary consent for the funding source was not documented in the client's record.
Client #3 was admitted on August 26, 2020 and was still active at the time of the inspection. An informed voluntary consent for the funding source was not documented in the client's record.
Client #4 was admitted on February 6, 2020 and was discharged on August 19, 2020. An informed voluntary consent for the funding source was not documented in the client's record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In addition to APM's current consent forms for the Release of Information to CBH (MA insurance provider), Logisticare (transportation), and ADL Laboratories, program participants will also sign Release of Information forms for their Emergency Contact and Primary Care Physician. These forms will have a boxes indicating the client was offered the ROI consent and either accepted or refused their consent.
Clinical Supervisor shall ensure compliance with APM's D&A intake and buprenorphine induction protocols covered in both individual and group supervisions, as well as part of regular review of progress notes on at least a monthly basis. APM's Quality Improvement Team will make compliance with follow up procedure a part of their random chart reviews.
Facility Director will 1) ensure all 3 clients' records will be updated with a valid informed and voluntary consent to release information by October 30, 2020, and 2) updated our signature collections process to include mailing documents that require a signature and / or allowing them to be picked up and dropped off during the clinic's administrative hours while treatment is being offered virtually. |
715.9(a)(1) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on a review of client records, the facility failed to screen each individual prior to the administration of a narcotic agent by not verifying an individual had reached 18 years of age in one of two applicable records reviewed.
Client #2 was admitted on August 25, 2020 and was still active at the time of the inspection. There was no documentation in the record that shows the verification of the client's age prior to their first dose.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All participants will undergo and intake into APM's D&A program and a face to face visit with APM's narcotic treatment physician before commencing buprenorphine treatment. Participants who present to MHOP needing narcotic treatment will be given an intake appointment to APM's D&A programs with an APM SUD Counselor and a doctor's appointment for buprenorphine induction with APM's board certified addiction treatment psychiatrist within 72 hours. APM's MHOP medical staff are NOT authorized to initiate narcotic treatment.
D&A intake includes:
1) Presentation of a valid picture ID, including the individual's DOB and copying that ID into the medical record for subsequent verification. This ID will be updated every three years as long as the patient is active in the program,
2) Signing APM's Consent to Buprenorphine treatment form,
3) Signing Releases of information to the individual's Emergency Contact, PCP, their medical insurance provider (ordinarily CBH), Logisticare, and Atlantic Diagnostic Laboratories,
4) Taking a urine sample to establish which drugs, if any, the individual has in their system.
The medical visit includes:
1) A conversation between APM's Addiction Treatment Psychiatrist and the individual regarding the risks and benefits of buprenorphine treatment, including any risks to a pregnant woman or the fetus.
2) Review of the patient record, confirming the individual's name, address, picture in the record, emergency contact, and other identifying information to confirm their eligibility for narcotic treatment.
3) Face to face determination by the narcotic treatment physician of the patient's current physiological dependence on a narcotic drug and of their dependence for the last year, including urinalysis.
During the Covid Emergency, APM will follow DEA's
"public health emergency exception to the Ryan Haight Act, which allows providers to prescribe controlled substances via telemedicine without first conducting an in-person examination. Under this emergency exception, practitioners can prescribe controlled substances to patients through the use of "telemedicine technologies," which requires the use of an audio-visual, real-time, two-way interactive communication system. (See our prior article for a more in-depth discussion of the Ryan Haight Act).
Recently, DEA further expanded this controlled substances prescribing exception for "authorized practitioners" treating OUD patients. According to a recent letter issued by DEA (the DEA Letter), in partnership with the Substance Abuse and Mental Health Services Administration (SAMHSA), as of March 31, 2020, the DEA will allow "authorized practitioners" to prescribe buprenorphine to new and existing OUD patients for maintenance or detoxification treatment on the basis of telehealth examination, which may include a telephone voice-only evaluation?without the need for a prior in-person exam. "
https://www.foley.com/en/insights/publications/2020/04/covid19-dea-samhsa-opioid-disorders-telehealth
APM will continue to follow DEA guidelines once the public health emergency is lifted and return to requiring face to face, in-person, examination of the participant prior to commencing buprenorphine treatment. Note that APM does NOT provide methadone treatment, which still requires an in-person examination.
Clinical Supervisor shall make compliance with APM's D&A intake and buprenorphine induction one topic covered in both individual and group supervisions, as well as part of regular review of progress notes on at least a monthly basis. APM's Quality Improvement Team will make compliance with follow up procedure a part of their random chart reviews.
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715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of client records, the facility failed to screen each individual prior to the administration of a narcotic agent by not verifying the individual's identity, including name, address, date of birth, emergency contact and other identifying data in two of two applicable records reviewed.
Client #1 was admitted on August 24, 2020 and was still active at the time of the inspection. There was no documentation in the record that verified the client's emergency contact.
Client #2 was admitted on August 25, 2020 and was still active at the time of the inspection. There was no documentation in the record that verified the client's emergency contact.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All participants will undergo and intake into APM's D&A program and a face to face visit with APM's narcotic treatment physician before commencing buprenorphine treatment. Participants who present to MHOP needing narcotic treatment will be given an intake appointment to APM's D&A programs with an APM SUD Counselor and a doctor's appointment for buprenorphine induction with APM's board certified addiction treatment psychiatrist within 72 hours. APM's MHOP medical staff are NOT authorized to initiate narcotic treatment.
D&A intake includes:
1) Presentation of a valid picture ID, including the individual's DOB and copying that ID into the medical record for subsequent verification. This ID will be updated every three years as long as the patient is active in the program,
2) Signing APM's Consent to Buprenorphine treatment form,
3) Signing Releases of information to the individual's Emergency Contact, PCP, their medical insurance provider (ordinarily CBH), Logisticare, and Atlantic Diagnostic Laboratories,
4) Taking a urine sample to establish which drugs, if any, the individual has in their system.
The medical visit includes:
1) A conversation between APM's Addiction Treatment Psychiatrist and the individual regarding the risks and benefits of buprenorphine treatment, including any risks to a pregnant woman or the fetus.
2) Review of the patient record, confirming the individual's name, address, picture in the record, emergency contact, and other identifying information to confirm their eligibility for narcotic treatment.
3) Face to face determination by the narcotic treatment physician of the patient's current physiological dependence on a narcotic drug and of their dependence for the last year, including urinalysis.
During the Covid Emergency, APM will follow DEA's
"public health emergency exception to the Ryan Haight Act, which allows providers to prescribe controlled substances via telemedicine without first conducting an in-person examination. Under this emergency exception, practitioners can prescribe controlled substances to patients through the use of "telemedicine technologies," which requires the use of an audio-visual, real-time, two-way interactive communication system. (See our prior article for a more in-depth discussion of the Ryan Haight Act).
Recently, DEA further expanded this controlled substances prescribing exception for "authorized practitioners" treating OUD patients. According to a recent letter issued by DEA (the DEA Letter), in partnership with the Substance Abuse and Mental Health Services Administration (SAMHSA), as of March 31, 2020, the DEA will allow "authorized practitioners" to prescribe buprenorphine to new and existing OUD patients for maintenance or detoxification treatment on the basis of telehealth examination, which may include a telephone voice-only evaluation?without the need for a prior in-person exam. "
https://www.foley.com/en/insights/publications/2020/04/covid19-dea-samhsa-opioid-disorders-telehealth
APM will continue to follow DEA guidelines once the public health emergency is lifted and return to requiring face to face, in-person, examination of the participant prior to commencing buprenorphine treatment. Note that APM does NOT provide methadone treatment, which still requires an in-person examination.
Clinical Supervisor shall make compliance with APM's D&A intake and buprenorphine induction one topic covered in both individual and group supervisions, as well as part of regular review of progress notes on at least a monthly basis. APM's Quality Improvement Team will make compliance with follow up procedure a part of their random chart reviews.
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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of client records, the facility failed to ensure that a narcotic treatment physician documented in the patient's record the basis for the determination of current dependency and evidence of a 1-year history of addiction in one of two applicable records reviewed.
Client #2 was admitted on August 25, 2020 and was still active at the time of the inspection. There was no documentation in the record showing the narcotic treatment physician's basis for the determination of the client's current dependency and evidence of a 1-year history of addiction.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All participants will undergo and intake into APM's D&A program and a face to face visit with APM's narcotic treatment physician before commencing buprenorphine treatment. Participants who present to MHOP needing narcotic treatment will be given an intake appointment to APM's D&A programs with an APM SUD Counselor and a doctor's appointment for buprenorphine induction with APM's board certified addiction treatment psychiatrist within 72 hours. APM's MHOP medical staff are NOT authorized to initiate narcotic treatment.
D&A intake includes:
1) Presentation of a valid picture ID, including the individual's DOB and copying that ID into the medical record for subsequent verification. This ID will be updated every three years as long as the patient is active in the program,
2) Signing APM's Consent to Buprenorphine treatment form,
3) Signing Releases of information to the individual's Emergency Contact, PCP, their medical insurance provider (ordinarily CBH), Logisticare, and Atlantic Diagnostic Laboratories,
4) Taking a urine sample to establish which drugs, if any, the individual has in their system.
The medical visit includes:
1) A conversation between APM's Addiction Treatment Psychiatrist and the individual regarding the risks and benefits of buprenorphine treatment, including any risks to a pregnant woman or the fetus.
2) Review of the patient record, confirming the individual's name, address, picture in the record, emergency contact, and other identifying information to confirm their eligibility for narcotic treatment.
3) Face to face determination by the narcotic treatment physician of the patient's current physiological dependence on a narcotic drug and of their dependence for the last year, including urinalysis.
During the Covid Emergency, APM will follow DEA's
"public health emergency exception to the Ryan Haight Act, which allows providers to prescribe controlled substances via telemedicine without first conducting an in-person examination. Under this emergency exception, practitioners can prescribe controlled substances to patients through the use of "telemedicine technologies," which requires the use of an audio-visual, real-time, two-way interactive communication system. (See our prior article for a more in-depth discussion of the Ryan Haight Act).
Recently, DEA further expanded this controlled substances prescribing exception for "authorized practitioners" treating OUD patients. According to a recent letter issued by DEA (the DEA Letter), in partnership with the Substance Abuse and Mental Health Services Administration (SAMHSA), as of March 31, 2020, the DEA will allow "authorized practitioners" to prescribe buprenorphine to new and existing OUD patients for maintenance or detoxification treatment on the basis of telehealth examination, which may include a telephone voice-only evaluation?without the need for a prior in-person exam. "
https://www.foley.com/en/insights/publications/2020/04/covid19-dea-samhsa-opioid-disorders-telehealth
APM will continue to follow DEA guidelines once the public health emergency is lifted and return to requiring face to face, in-person, examination of the participant prior to commencing buprenorphine treatment. Note that APM does NOT provide methadone treatment, which still requires an in-person examination.
Clinical Supervisor shall make compliance with APM's D&A intake and buprenorphine induction one topic covered in both individual and group supervisions, as well as part of regular review of progress notes on at least a monthly basis. APM's Quality Improvement Team will make compliance with follow up procedure a part of their random chart reviews.
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715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
Based on a review of client records, the facility failed to document that each female patient was fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment in two of two applicable records reviewed.
Client #1 was admitted on August 24, 2020 and was still active at the time of the inspection. There was no documentation that the patient was informed of the possible risk to her from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program.
Client #2 was admitted on August 25, 2020 and was still active at the time of the inspection. There was no documentation that the patient was informed of the possible risk to her from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All participants will undergo and intake into APM's D&A program and a face to face visit with APM's narcotic treatment physician before commencing buprenorphine treatment. Participants who present to MHOP needing narcotic treatment will be given an intake appointment to APM's D&A programs with an APM SUD Counselor and a doctor's appointment for buprenorphine induction with APM's board certified addiction treatment psychiatrist within 72 hours. APM's MHOP medical staff are NOT authorized to initiate narcotic treatment.
D&A intake includes:
1) Presentation of a valid picture ID, including the individual's DOB and copying that ID into the medical record for subsequent verification. This ID will be updated every three years as long as the patient is active in the program,
2) Signing APM's Consent to Buprenorphine treatment form,
3) Signing Releases of information to the individual's Emergency Contact, PCP, their medical insurance provider (ordinarily CBH), Logisticare, and Atlantic Diagnostic Laboratories,
4) Taking a urine sample to establish which drugs, if any, the individual has in their system.
The medical visit includes:
1) A conversation between APM's Addiction Treatment Psychiatrist and the individual regarding the risks and benefits of buprenorphine treatment, including any risks to a pregnant woman or the fetus.
2) Review of the patient record, confirming the individual's name, address, picture in the record, emergency contact, and other identifying information to confirm their eligibility for narcotic treatment.
3) Face to face determination by the narcotic treatment physician of the patient's current physiological dependence on a narcotic drug and of their dependence for the last year, including urinalysis.
During the Covid Emergency, APM will follow DEA's
"public health emergency exception to the Ryan Haight Act, which allows providers to prescribe controlled substances via telemedicine without first conducting an in-person examination. Under this emergency exception, practitioners can prescribe controlled substances to patients through the use of "telemedicine technologies," which requires the use of an audio-visual, real-time, two-way interactive communication system. (See our prior article for a more in-depth discussion of the Ryan Haight Act).
Recently, DEA further expanded this controlled substances prescribing exception for "authorized practitioners" treating OUD patients. According to a recent letter issued by DEA (the DEA Letter), in partnership with the Substance Abuse and Mental Health Services Administration (SAMHSA), as of March 31, 2020, the DEA will allow "authorized practitioners" to prescribe buprenorphine to new and existing OUD patients for maintenance or detoxification treatment on the basis of telehealth examination, which may include a telephone voice-only evaluation?without the need for a prior in-person exam. "
https://www.foley.com/en/insights/publications/2020/04/covid19-dea-samhsa-opioid-disorders-telehealth
APM will continue to follow DEA guidelines once the public health emergency is lifted and return to requiring face to face, in-person, examination of the participant prior to commencing buprenorphine treatment. Note that APM does NOT provide methadone treatment, which still requires an in-person examination.
Clinical Supervisor shall make compliance with APM's D&A intake and buprenorphine induction one topic covered in both individual and group supervisions, as well as part of regular review of progress notes on at least a monthly basis. APM's Quality Improvement Team will make compliance with follow up procedure a part of their random chart reviews.
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715.13(a) LICENSURE Patient identification
(a) A narcotic treatment program shall use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
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Observations
Based on a review of client records, the facility failed to use a system for patient identification for the purpose of verifying the correct identity of a client prior to administration of an agent in two of two applicable records reviewed.
Client #1 was admitted on August 24, 2020 and was still active at the time of the inspection.
Client #2 was admitted on August 25, 2020 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All participants will undergo and intake into APM's D&A program and a face to face visit with APM's narcotic treatment physician before commencing buprenorphine treatment. Participants who present to MHOP needing narcotic treatment will be given an intake appointment to APM's D&A programs with an APM SUD Counselor and a doctor's appointment for buprenorphine induction with APM's board certified addiction treatment psychiatrist within 72 hours. APM's MHOP medical staff are NOT authorized to initiate narcotic treatment.
D&A intake includes:
1) Presentation of a valid picture ID, including the individual's DOB and copying that ID into the medical record for subsequent verification. This ID will be updated every three years as long as the patient is active in the program,
2) Signing APM's Consent to Buprenorphine treatment form,
3) Signing Releases of information to the individual's Emergency Contact, PCP, their medical insurance provider (ordinarily CBH), Logisticare, and Atlantic Diagnostic Laboratories,
4) Taking a urine sample to establish which drugs, if any, the individual has in their system.
The medical visit includes:
1) A conversation between APM's Addiction Treatment Psychiatrist and the individual regarding the risks and benefits of buprenorphine treatment, including any risks to a pregnant woman or the fetus.
2) Review of the patient record, confirming the individual's name, address, picture in the record, emergency contact, and other identifying information to confirm their eligibility for narcotic treatment.
3) Face to face determination by the narcotic treatment physician of the patient's current physiological dependence on a narcotic drug and of their dependence for the last year, including urinalysis.
During the Covid Emergency, APM will follow DEA's
"public health emergency exception to the Ryan Haight Act, which allows providers to prescribe controlled substances via telemedicine without first conducting an in-person examination. Under this emergency exception, practitioners can prescribe controlled substances to patients through the use of "telemedicine technologies," which requires the use of an audio-visual, real-time, two-way interactive communication system. (See our prior article for a more in-depth discussion of the Ryan Haight Act).
Recently, DEA further expanded this controlled substances prescribing exception for "authorized practitioners" treating OUD patients. According to a recent letter issued by DEA (the DEA Letter), in partnership with the Substance Abuse and Mental Health Services Administration (SAMHSA), as of March 31, 2020, the DEA will allow "authorized practitioners" to prescribe buprenorphine to new and existing OUD patients for maintenance or detoxification treatment on the basis of telehealth examination, which may include a telephone voice-only evaluation?without the need for a prior in-person exam. "
https://www.foley.com/en/insights/publications/2020/04/covid19-dea-samhsa-opioid-disorders-telehealth
APM will continue to follow DEA guidelines once the public health emergency is lifted and return to requiring face to face, in-person, examination of the participant prior to commencing buprenorphine treatment. Note that APM does NOT provide methadone treatment, which still requires an in-person examination.
Clinical Supervisor shall make compliance with APM's D&A intake and buprenorphine induction one topic covered in both individual and group supervisions, as well as part of regular review of progress notes on at least a monthly basis. APM's Quality Improvement Team will make compliance with follow up procedure a part of their random chart reviews.
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715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on a review of client records, the facility failed to maintain onsite a photograph of the client, which includes the patient's name and birth date in one of two applicable records reviewed.
Client #2 was admitted on August 25, 2020 and was still active at the time of the inspection. There was no current photograph of the client documented in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All participants will undergo and intake into APM's D&A program and a face to face visit with APM's narcotic treatment physician before commencing buprenorphine treatment. Participants who present to MHOP needing narcotic treatment will be given an intake appointment to APM's D&A programs with an APM SUD Counselor and a doctor's appointment for buprenorphine induction with APM's board certified addiction treatment psychiatrist within 72 hours. APM's MHOP medical staff are NOT authorized to initiate narcotic treatment.
D&A intake includes:
1) Presentation of a valid picture ID, including the individual's DOB and copying that ID into the medical record for subsequent verification. This ID will be updated every three years as long as the patient is active in the program,
2) Signing APM's Consent to Buprenorphine treatment form,
3) Signing Releases of information to the individual's Emergency Contact, PCP, their medical insurance provider (ordinarily CBH), Logisticare, and Atlantic Diagnostic Laboratories,
4) Taking a urine sample to establish which drugs, if any, the individual has in their system.
The medical visit includes:
1) A conversation between APM's Addiction Treatment Psychiatrist and the individual regarding the risks and benefits of buprenorphine treatment, including any risks to a pregnant woman or the fetus.
2) Review of the patient record, confirming the individual's name, address, picture in the record, emergency contact, and other identifying information to confirm their eligibility for narcotic treatment.
3) Face to face determination by the narcotic treatment physician of the patient's current physiological dependence on a narcotic drug and of their dependence for the last year, including urinalysis.
During the Covid Emergency, APM will follow DEA's
"public health emergency exception to the Ryan Haight Act, which allows providers to prescribe controlled substances via telemedicine without first conducting an in-person examination. Under this emergency exception, practitioners can prescribe controlled substances to patients through the use of "telemedicine technologies," which requires the use of an audio-visual, real-time, two-way interactive communication system. (See our prior article for a more in-depth discussion of the Ryan Haight Act).
Recently, DEA further expanded this controlled substances prescribing exception for "authorized practitioners" treating OUD patients. According to a recent letter issued by DEA (the DEA Letter), in partnership with the Substance Abuse and Mental Health Services Administration (SAMHSA), as of March 31, 2020, the DEA will allow "authorized practitioners" to prescribe buprenorphine to new and existing OUD patients for maintenance or detoxification treatment on the basis of telehealth examination, which may include a telephone voice-only evaluation?without the need for a prior in-person exam. "
https://www.foley.com/en/insights/publications/2020/04/covid19-dea-samhsa-opioid-disorders-telehealth
APM will continue to follow DEA guidelines once the public health emergency is lifted and return to requiring face to face, in-person, examination of the participant prior to commencing buprenorphine treatment. Note that APM does NOT provide methadone treatment, which still requires an in-person examination.
Clinical Supervisor shall make compliance with APM's D&A intake and buprenorphine induction one topic covered in both individual and group supervisions, as well as part of regular review of progress notes on at least a monthly basis. APM's Quality Improvement Team will make compliance with follow up procedure a part of their random chart reviews.
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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 a review of client records, the facility failed to complete an initial drug-screening urinalysis for each prospective client in two of two applicable records reviewed.
Client #1 was admitted on August 24, 2020 and was still active at the time of the inspection. An initial drug-screening urinalysis was not documented in the record prior to the initial dose on August 28, 2020.
Client #2 was admitted on August 25, 2020 and was still active at the time of the inspection. An initial drug-screening urinalysis was not documented in the record prior to the initial dose on August 25, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All participants will undergo and intake into APM's D&A program and a face to face visit with APM's narcotic treatment physician before commencing buprenorphine treatment. Participants who present to MHOP needing narcotic treatment will be given an intake appointment to APM's D&A programs with an APM SUD Counselor and a doctor's appointment for buprenorphine induction with APM's board certified addiction treatment psychiatrist within 72 hours. APM's MHOP medical staff are NOT authorized to initiate narcotic treatment.
D&A intake includes:
1) Presentation of a valid picture ID, including the individual's DOB and copying that ID into the medical record for subsequent verification. This ID will be updated every three years as long as the patient is active in the program,
2) Signing APM's Consent to Buprenorphine treatment form,
3) Signing Releases of information to the individual's Emergency Contact, PCP, their medical insurance provider (ordinarily CBH), Logisticare, and Atlantic Diagnostic Laboratories,
4) Taking a urine sample to establish which drugs, if any, the individual has in their system.
The medical visit includes:
1) A conversation between APM's Addiction Treatment Psychiatrist and the individual regarding the risks and benefits of buprenorphine treatment, including any risks to a pregnant woman or the fetus.
2) Review of the patient record, confirming the individual's name, address, picture in the record, emergency contact, and other identifying information to confirm their eligibility for narcotic treatment.
3) Face to face determination by the narcotic treatment physician of the patient's current physiological dependence on a narcotic drug and of their dependence for the last year, including urinalysis.
During the Covid Emergency, APM will follow DEA's
"public health emergency exception to the Ryan Haight Act, which allows providers to prescribe controlled substances via telemedicine without first conducting an in-person examination. Under this emergency exception, practitioners can prescribe controlled substances to patients through the use of "telemedicine technologies," which requires the use of an audio-visual, real-time, two-way interactive communication system. (See our prior article for a more in-depth discussion of the Ryan Haight Act).
Recently, DEA further expanded this controlled substances prescribing exception for "authorized practitioners" treating OUD patients. According to a recent letter issued by DEA (the DEA Letter), in partnership with the Substance Abuse and Mental Health Services Administration (SAMHSA), as of March 31, 2020, the DEA will allow "authorized practitioners" to prescribe buprenorphine to new and existing OUD patients for maintenance or detoxification treatment on the basis of telehealth examination, which may include a telephone voice-only evaluation?without the need for a prior in-person exam. "
https://www.foley.com/en/insights/publications/2020/04/covid19-dea-samhsa-opioid-disorders-telehealth
APM will continue to follow DEA guidelines once the public health emergency is lifted and return to requiring face to face, in-person, examination of the participant prior to commencing buprenorphine treatment. Note that APM does NOT provide methadone treatment, which still requires an in-person examination.
Clinical Supervisor shall make compliance with APM's D&A intake and buprenorphine induction one topic covered in both individual and group supervisions, as well as part of regular review of progress notes on at least a monthly basis. APM's Quality Improvement Team will make compliance with follow up procedure a part of their random chart reviews.
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709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records, the facility failed to include the documentation of consent to treatment forms during their intake process in two of four records reviewed.
Client #1 was admitted on August 24, 2020 and was still active at the time of the inspection. A consent to treatment was not documented in the client's records.
Client #2 was admitted on August 25, 2020 and was still active at the time of the inspection. A consent to treatment was not documented in the client's records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All participants will undergo and intake into APM's D&A program and a face to face visit with APM's narcotic treatment physician before commencing buprenorphine treatment. Participants who present to MHOP needing narcotic treatment will be given an intake appointment to APM's D&A programs with an APM SUD Counselor and a doctor's appointment for buprenorphine induction with APM's board certified addiction treatment psychiatrist within 72 hours. APM's MHOP medical staff are NOT authorized to initiate narcotic treatment.
D&A intake includes:
1) Presentation of a valid picture ID, including the individual's DOB and copying that ID into the medical record for subsequent verification. This ID will be updated every three years as long as the patient is active in the program,
2) Signing APM's Consent to Buprenorphine treatment form,
3) Signing Releases of information to the individual's Emergency Contact, PCP, their medical insurance provider (ordinarily CBH), Logisticare, and Atlantic Diagnostic Laboratories,
4) Taking a urine sample to establish which drugs, if any, the individual has in their system.
The medical visit includes:
1) A conversation between APM's Addiction Treatment Psychiatrist and the individual regarding the risks and benefits of buprenorphine treatment, including any risks to a pregnant woman or the fetus.
2) Review of the patient record, confirming the individual's name, address, picture in the record, emergency contact, and other identifying information to confirm their eligibility for narcotic treatment.
3) Face to face determination by the narcotic treatment physician of the patient's current physiological dependence on a narcotic drug and of their dependence for the last year, including urinalysis.
During the Covid Emergency, APM will follow DEA's
"public health emergency exception to the Ryan Haight Act, which allows providers to prescribe controlled substances via telemedicine without first conducting an in-person examination. Under this emergency exception, practitioners can prescribe controlled substances to patients through the use of "telemedicine technologies," which requires the use of an audio-visual, real-time, two-way interactive communication system. (See our prior article for a more in-depth discussion of the Ryan Haight Act).
Recently, DEA further expanded this controlled substances prescribing exception for "authorized practitioners" treating OUD patients. According to a recent letter issued by DEA (the DEA Letter), in partnership with the Substance Abuse and Mental Health Services Administration (SAMHSA), as of March 31, 2020, the DEA will allow "authorized practitioners" to prescribe buprenorphine to new and existing OUD patients for maintenance or detoxification treatment on the basis of telehealth examination, which may include a telephone voice-only evaluation?without the need for a prior in-person exam. "
https://www.foley.com/en/insights/publications/2020/04/covid19-dea-samhsa-opioid-disorders-telehealth
APM will continue to follow DEA guidelines once the public health emergency is lifted and return to requiring face to face, in-person, examination of the participant prior to commencing buprenorphine treatment. Note that APM does NOT provide methadone treatment, which still requires an in-person examination.
Clinical Supervisor shall make compliance with APM's D&A intake and buprenorphine induction one topic covered in both individual and group supervisions, as well as part of regular review of progress notes on at least a monthly basis. APM's Quality Improvement Team will make compliance with follow up procedure a part of their random chart reviews.
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709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document a complete client record which is to include follow-up information in one of one applicable records reviewed.
Client #4 was admitted on February 6, 2020 and was discharged on August 19, 2020. There was no follow-up information documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
APM staff shall update the client record within 72 hours of every encounter with the client. Should a client drop out of the program, APM staff will record non-billable notes of their attempts to contact the client within 72 hours of every attempt.
Further, APM staff shall contact participants during the first two weeks after their discharge from the program to ensure they are following through with their discharge plan and will record this contact in a non-billable note.
This follow-up of discharged participants shall be discussed during individual and group supervision.
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