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 June 26-29, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health System 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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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of administrative documentation, the facility failed to provide at least one hour of physician time a week, on site, for every ten patients for five of the eight weeks reviewed.
The findings include:
Physician time sheets for the months of March, April, May and June were reviewed on June 27, 2012. Eight weeks were chosen and the director was asked to provide the patient census for those eight weeks. Five weeks provided insufficient onsite physician hours during April and May 2012.
During the week of April 29, 2012, the patient census was 617. The facility was required to provide at least 61.7 physician hours. There were 60 physician hours documented. The amount of physician hours documented was less than the amount of hours required.
During the week of May 6, 2012, the patient census was 630. The facility was required to provide at least 63 physician hours. There were 48 physician hours documented. The amount of physician hours documented was less than the amount of hours required.
During the week of May 13, 2012, the patient census was 630. The facility was required to provide at least 63 physician hours. There were 48 physician hours documented. The amount of physician hours documented was less than the amount of hours required.
During the week of May 20, 2012, the patient census was 630. The facility was required to provide at least 63 physician hours. There were 60 physician hours documented. The amount of physician hours documented was less than the amount of hours required.
During the week of May 27, 2012, the patient census was 630. The facility was required to provide at least 63 physician hours. There were 58 physician hours documented. The amount of physician hours documented was less than the amount of hours required.
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Plan of Correction
1. Clinical coordinator will inform director of physician scheduling conflicts that effect program coverage .
2.Director will monitor and coordinate physician hours to provide patient coverage based on census.
3.Director will request addition physician coverage from administration, due to vacations or other reasons that might effect medical staffing.
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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 the review of patient records, the facility failed to ensure at least monthly random urine drug screens for fourteen of twenty-nine patient records.
The findings include:
Thirty one patient records were reviewed June 26-29, 2012. Twenty nine patient records were reviewed specifically for monthly random urine drug screens. Fourteen patient records failed to have at least monthly random urine drug screens, # 3, 6, 7, 9, 10, 13, 14, 15, 18, 21, 22, 25, 26, and 27.
Patient record # 3 failed to have a documented urine drug screen for the month of May 2012 in the record, at the time of the survey.
Patient record # 6 failed to have a documented urine drug screen for the months of December 2011, January 2012, April 2012 and May 2012 in the record, at the time of the survey.
Patient record # 7 failed to have a documented urine drug screen for the months of April and May 2012 in the record, at the time of the survey.
Patient record # 9 failed to have a documented urine drug screen for the month of March 2012 in the record, at the time of the survey.
Patient # 10 was admitted May 1, 2012. The patient had the initial admission urine drug screen, but there were no other urine drug screens since the admission in the record, at the time of the survey.
Patient record # 13 failed to have a documented urine drug screen for the months of November and December 2011 in the record, at the time of the survey.
Patient record # 14 failed to have a documented urine drug screen for the months of January and March 2012 in the record, at the time of the survey.
Patient record # 15 failed to have a documented urine drug screen for the months of February and May 2012 in the record, at the time of the survey.
Patient record # 18 failed to have a documented urine drug screen for the month of December 2011 in the record, at the time of the survey.
Patient record # 21 failed to have a documented urine drug screen for the month of January 2012 in the record, at the time of the survey.
Patient record # 22 failed to have a documented urine drug screen for the month of May 2012 in the record, at the time of the survey.
Patient record # 25 failed to have a documented urine drug screen for the month of January 2012 in the record, at the time of the survey.
Patient record # 26 failed to have a documented urine drug screen for the month of May 2012 in the record, at the time of the survey.
Patient record # 27 failed to have a documented urine drug screen for the month of April 2012 in the record, at the time of the survey.
The urine drug screen documentation not found in the patient records was requested of the facility director, but was not provided.
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Plan of Correction
1.Director will review urinalysis processing process for abidance to policy 715.14 urine drug screens during the next sixty day period
2.The check-in clerk will be responsible for printing a list from the Avatar client information system.
3.The nursing staff will schedule and collect all samples for the day. The nursing staff and check-in clerk will review the list daily to ensure all patients are being tested monthly.
4.The test results will be reviewed and signed by the medical director before filing those in the patient's
chart.
5.Clinical supervisors will review (48)charts within sixty days for compliance to policy 715.14 urine drug screens with a 100% benchmark.
6.Medical record staff will record dates urine drug screens were taken in charts and report to Director , if any are missing. |
715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document what materials were sent to the receiving narcotic treatment program in two of three patient records.
The findings include:
Thirty one patient records were reviewed June 26-29, 2012. Three patient records required documentation of the materials sent to the receiving provider of the transfer. Two patient records failed to have documented what materials were sent to the receiving facilities. In patient records # 22 and 25 there was no documentation of the materials sent to the receiving narcotic treatment programs.
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Plan of Correction
1.The Primary Counselor will secure the following materials from the chart and send to the receiving MAT: admission date, medical and psychosocial summaries, current status report, dosage level, urinalysis reports (last six months), exception requests and the client's signed consent.
2.Counselor will fax facsimile check-off with documentation to receiving MAT program. Counselor will review fax confirmation to verify that receiving MAT documentation was received. In conjunction counselor will make phone contact to verify all documentation was received by receiving MAT program. Clinical supervisior will review transfer PIR charts for 100% compliance
3.Clinical supervisors will provide supervision and in service trainings for clinical staff on PIR transfer
procedures within the next thirty days. |
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 patient records and administrative documentation, the facility failed to restrict the reasons for involuntary termination to those reasons allowed by regulation in two of four patient records.
The findings include:
Thirty one patient records were reviewed June 26-29, 2012. Four patient records were reviewed for documentation of discharge for non-compliance.
Patient # 18 received a notice of involuntary termination for loitering April 13, 2012. The patient had received a notice of involuntary termination on February 23, 2012 with the reason initially stating "excessive loitering", which was then crossed out and "failure to follow treatment rules and regulations" was added.
Patient # 26 was given a notice of involuntary termination June 6, 2012 for being "excessively absent" from the program. However, documentation demonstrated patient had attended more hours than required the three months prior to the notice. At no time did the patient miss consecutive dosing days to warrant a discharge for absences.
Administrative documentation that included a document entitled North Philadelphia Health System Goldman Clinic Community Informational Handout listed areas not included in regulation. Areas included for detoxification not addressed by regulation were "deliberately damaging or defacing clinic or hospital property," and "misuse of methadone: any use other than that prescribed by the clinic physician and removal or attempt to remove methadone form the dispensing area or clinic" none of which is allowed by regulation, without addressing it clinically. The document also included a section that addressed loitering and deemed loitering to be a behavior that warranted administrative detoxification.
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Plan of Correction
1.Administration will review and revise policy 715.21 to bring it in-line with chapter 715. Standards within next sixty days.
2.The policy on patient termination will be restricted to the 715 standards.Clinical supervisors will provide a in-service on 715.21(1)i-iv standard during team meetings on 8/6/12. Clinical supervisors will review terminations for 100% compliance to the standard.Process of reinforcing the importance of abiding by 715.21(1)i-iv began on 8/3/2012 during a general staff meeting chaired by Director. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on a review of patient records, the facility failed to document all of the required information in seven of ten patient records.
The findings include:
Thirty one patient records were reviewed June 27-28, 2012. Ten patient records required documented and complete discharge summaries.
Patient records # 18, 19, 21, 23 and 24 failed to document the reasons for entering treatment when they did.
Patient records # 17, 19, 21, and 23 did not document a response to the treatment process, but a general statement focused on the discharge reason or attendance of the patient.
Patient records # 16 and 19 did not document all services offered to the patient during the course of their treatment, specifically, that the patient received pharmacotherapy, a prime aspect of the treatment at this facility.
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Plan of Correction
1.Clinical supervisors will review discharge summaries for completion of all fields on form . The benchmark is a 100% completion rate.
2.Clinical supervisors will provide supervision and in-service trainings for clinical staff on discharge ummary procedures within sixty days.
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715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on the review of patient records, the facility failed to document the attempt or completion of patient follow up contact in two of three patient records reviewed.
The findings include:
Thirty one patient records were reviewed June 26-29, 2012. Nine patient records required documentation of an attempt or completion of a follow up contact. Three of the nine were transferred/referred to other treatment programs and required a follow up attempt within seven days of the referral appointment. Two of those three had no documentation of any follow up attempts.
Patient # 16 was discharged as having completed treatment on March 12, 2012 and referred to another treatment provider. The follow up contact was required to have been attempted within seven days of the referral appointment. This follow up was not completed at the time of the inspection.
Patient # 25 was discharged as a transfer to another treatment facility April 9, 2012. The follow up contact was required to have been attempted within seven days of the referral appointment. This follow up was not completed at the time of the inspection.
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Plan of Correction
1. Clinical supervisors will provide supervision and in-service trainings for clinical staff on follow-up procedures to ensure that the deficiences do not recur.
2. Clinical supervisors will audit (48)forty -eight chart for completion of follow-up procudures as stated in policy 711.94. Clinical supervisors will monitor follow-up benchmark completion rate ,the goal is 100% percent.
3. Director will provide supervision and in-service trainings for clinic coordinator on follow-up procedures.
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715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on review of administrative documentation provided during the inspection and staff interviews, the facility failed to submit documentation of unusual incidents to the Department as required.
The findings include:
Administrative documentation that included the policy and procedure manual and documentation of unusual incidents that occurred at the facility was reviewed June 27-29, 2012.
April 3, 2012 a patient was medicated at approximately 7:30 AM and then was found unresponsive in the main building about 9:00 AM. Patient was transported to another hospital via ambulance.
April 4, 2012 a patient was found to be behaving irrationally, passed out and unresponsive. Medics arrived to take patient to hospital. It was determined patient had taken several substances in addition to the prescribed methadone.
April 5, 2012 a patient was found unresponsive in main building. The patient was transported to a local hospital.
May 22, 2012 a patient was observed in lobby appearing to be disoriented. Rescue squad called to transport patient to hospital ER.
None of the unusual incidents documented were reported to the Department as required.
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Plan of Correction
1.Clinical supervisors will provide supervision and in-service trainings for clinical staff on unusual incident
report procedures within sixty days .
2.Unusual incidents will be documented and reported to Director and DBH within 24 hrs.
3.Clinical coordinator will fax and file unusual incidents reports with confirmations.
4.Director will reinforce the importance of following policy 715.28 during the next general staff meeting
within thirty days.
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