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 August 17, 18 and 19, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Narcotic Addict Rehabilitation Program was found not to be in compliance with the applicable chapters of 4 PA Code and 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on September 10, 2009.
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Plan of Correction
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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 patient records and staff interview the facility failed to have a narcotic treatment physician document a patient's current diagnosis of dependency in one of eight patient records.
Findings:
Twenty one patient records were reviewed August 17 - 19, 2009. Eight were required to provide documentation of current dependency at time of admission. Patient record # 11 failed to contain documentation of opiate dependency; the forms utilized by facility physician were not completed in this patient record. Staff interviewed acknowledged physician practice for the admission of patients and confirmed the documentation was not in patient record # 11.
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Plan of Correction
Unfortunately the evaluating physician failed to complete the dependency section of the form. The medical director has emphasized to all medical staff the need for completing the dependency section at admission. Random review of charts condcuted by administrative personnel (inc. the program coordinator and medical director) should prevent future occurrences. |
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 a review of patient records, the facility failed to complete consents to release information forms in accordance with 42 CFR 22 and 709.28 in one of seventeen patient records.
The findings include:
Twenty one records were reviewed August 17 - 19, 2009; seventeen records were reviewed for compliance with issues pertaining to confidentiality. Patient record # 12 contained a consent to release information form that was signed by the patient but failed to identify the source for the information to be released to as well as the information to be released. Consent forms are required to be completed prior to patient signature.
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Plan of Correction
The issue of incomplete consent forms was addressed directly with the counselor by the clinical supervisor. In addition, this issue was addressed in a full staff meeting conducted by the Program Coordinator and Coordinator of Treatment in August 21, 2009. Ongoing review of charts condcuted by clinical supervisors should insure that no future episodes occur. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on a review of patient records and staff interviews, the facility failed to ensure the physician was the person determining patient doses in four of eight records.
The findings include.
Twenty one records were reviewed August 17 - 19, 2009; eight were reviewed for dose determination content. The documentation in the patient records 7, 8, 11 and 12 revealed the facility utilized a dose change request form that permitted clinical staff to enter a specific recommendation for a patient's dose change. Staff interviews confirmed this practice. Only a physician may determine the patient's dose.
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Plan of Correction
The dose change request form has been modified by the Medical Director. In response to this deficiency, clinical staff have been educated by the Program Coordinator and Medical Director about the correct way to complete the form. Furthermore they have been told that they are not to make any recommendations about dose. The purpose of the form is only to inform the medical staff that a patient has requested a change in dose. If appropriate, the physician will then indicate the dose change. It shall be the responsibility of the medical director and/or her designates (i.e., associate medical director) to refuse to accept any forms that have had a specific dose request pre-entered. |
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 staff interviews, the facility failed to restrict the reasons for involuntary termination to those reasons allowed by regulation in 2 of four records.
The findings include:
Twenty one records were reviewed August 17 - 19, 2009. Four patient records were reviewed for involuntary, or therapeutic, discharge. Two patient records contained documentation of the patient being discharged for reasons other than those listed by regulation. Patients # 1 and 2 were discharged for reasons identified as financial noncompliance. Staff interviews confirmed the reasons for the discharges regarding these two patients.
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Plan of Correction
Staff are being trained in the proper use of, as well as the limits of involuntary discharge. A series of behavioral contracts that are in accord with the regulatory limits are being established. Failure to uphold these behavioral contracts can lead to escalating disciplinary action being taken, up to and including discharge from treatment. The Division Director, Facility Director, Coordinator of Treatment and Program Coordinator are all involved in this process. Compliance is the responsibility of the program coordinator. |
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 provide follow-up services in one of four patient records reviewed.
The findings include:
Twenty one patient records were reviewed August 17 - 19, 2009; four were reviewed for documentation of follow-up information. Patient record # 3 failed to contain documentation that a follow-up had been attempted following patient discharge.
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Plan of Correction
Failing to attempt post-discharge follow-up on one of former patients eligible for such contact clearly was an oversight. The program coordinator and clinical supervisor have reviewed with staff the importance of post-discharge follow-up. Chart reviwes conducted by progarm adminstrative personnel should ensure that follow-up attempts are being made. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on review of patient records, the facility failed to ensure that all annual evaluations were completed as required.
The findings include:
Twenty one patient records were reviewed August 17 - 19, 2009; five were reviewed for annual evaluation content. Patient record # 19 contained documentation that pertained to a patient evaluation for 2008 however this document failed to provide a clinical evaluation of the patient's status as it contained brief statements that did not assess or evaluate the patient's status in treatment.
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Plan of Correction
The program coordinator and program supervisor are offering training and supervision aaround the issue of annual evaluations. The Coordinator of Treatment and Training is responsible for seeing that this is completed. |
715.23(d)(1) 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.
(1) The treatment plan shall identify the behavioral tasks a patient shall perform to complete each short-term goal.
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Observations
Based on the review of patient records, the narcotic treatment program failed to document treatment plans in 6 of 16 patient records..
The findings include:
Twenty one patient records were reviewed on August 17 -19, 2009. Treatment plans were required in sixteen patient records. The narcotic treatment program failed to include support services in patient records # 3, 11,13, 16, 20 and 21.
Additionally, patient records # 7, 11, 12, 13, 17 and 19 failed to contain treatment plans that included measurable goals.
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Plan of Correction
Treatment planning documents are once again being revised by the Coordinator of Treatment and clinical supervisors. The "new" forms emphasize objective, measurable short and long-term goals. The new form, which is currently being implemented, also includes requirements for counselors to indicate support services available to the patient. |