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 and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on April 21-23, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Aldie Foundation Inc. 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 May 20, 2009.
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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 and discussion with staff, the facility failed to provide at least 1 hour per week of physician services for every ten patients enrolled for three of sixteen weeks reviewed.
The findings include:
The facility's licensed activity capacity was 200. The monitoring questionnaire, provided to the licensing specialists on April 21, 2009, recorded the medical director's regular hours as being 18.5 hours per week with another physician listed as the narcotic treatment physician as PRN. There were no time sheets submitted for review of this physician. The medical director's hours were reviewed for the period of December 29, 2008 through April 19, 2009. During this time period there were three weeks when the physician hours did not meet the required regulation that specific 1 hour of physician care for every 10 patients.
The week of December 29, 2008 through January 4, 2009, there were 11 physician hours recorded for a census of 155.
The week of February 16, 2009 through February 22, 2009, there were 9 physician hours recorded for a census of 157.
The week of March 23, 2009 through March 29, 2009, there were 14.5 physician hours recorded for a census of 154.
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Plan of Correction
Currently we have one Medical Director who is contracted to provide 18.5 hours per week. The Medical Dierector has been instructed on the regulations regarding physican treatment services to ensure that their is a clear understanding of the onsite requirements. Secondly the Narcotic Treatment Physician identified for PRN Services will be contracted for coverage in the absence of the Medical Director on a weekly basis. Also, beginning in the near future a new physician is being hired to provide an additional 10 hours on site which will also support the physician staffing requirements. The Program Coordinator will maintain oversight and insure compliance with the ratio of Narcotic Treatment Physician hours to current census on a weekly basis. Aldie has also identifed a clear system to document Narcotic treatment Physician hours based on direct work or time dedicated to the Narcotic Treatment Program and the Program Coordinator will insure that this is provided for all physicians during monitoring visits. |
715.9(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
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Observations
Based on the review of patient records, the facility failed to contact the previous treatment programs for the treatment history in two of two patient records.
The findings include:
Twelve patient records were reviewed April 21-23, 2009. Prior treatment history was required in two patient records. There was no documentation of any attempts to contact the prior narcotic treatment facilities for records # 3 and 11.
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Plan of Correction
The Assessment Coordinator provided a training for the Assessment Team on 5/18/09 regarding the procedure in place for previous narcotic treament programs to be contacted at the time of admission, utilizing the Pre-Admit Records request form. The Pharmacotherapy Coordinator will maintain oversight by reviewing and documenting that this form and appropriate releases have been completed and submitted prior to intake to insure compliance with this requirement. |
715.17(a) LICENSURE Medication control
(a) A narcotic treatment program shall comply with applicable Federal and State statutes and regulations regarding the storing, compounding, administering and dispensing of medication.
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Observations
Based on the review of patient records and discussion with staff, the facility failed to comply with Federal regulations regarding the administering of medication.
The findings include:
Twelve patient records were reviewed on April 21-23, 2009. Patient # 7 was admitted September 15, 2008. She was initially dosed at 60 milligrams on October 3, 2008. Federal regulations 42 Part 8, states "the initial dose of methadone shall not exceed 30 milligrams and the total dose for the first day shall not exceed 40 milligrams, unless the program physician documents in the patient's record that 40 milligrams did not suppress opiate abstinence symptoms". The initial dose was 60 milligrams and there was no documentation stating the rationale for this dose nor was there documentation that an exception had been received to dose the patient at that dose.
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Plan of Correction
Written Policy and Procedure was reviewed by the Quality Assurance Officer to reflect the Federal and State regulatory limitations and exceptions for dose induction limitations. The Pharmacotherapy Coordinator reviewed these regulations with the Medical Director to insure future compliance. The Pharmacotherapy Coordinator developed a protocol with the Medical Director that identifies that any patient who is noted to be a candidate for an initial induction dose in excess of 30 mgs must be reviewed for exception request by both the Pharmacotherapy Coordinator and the Medical Director and rational for this dose must be documented in an exception request. The Pharmacotherapy Coordinator will submit the Medical Director's exception request to the Federal Agency overseeing this regulation prior to the patients induction to the NTP |
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 the review of patient records, the facility failed to document what materials were sent to the receiving narcotic treatment facility in one of one patient records.
The findings include:
Twelve patient records were reviewed on April 21-23, 2009. Documentation of what materials were sent to a receiving narcotic treatment facility was required in one patient record, # 4. There was no documentation to indicate what information was sent to the receiving facility to complete the transfer of the patient, who was discharged March 9, 2009.
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Plan of Correction
A procedure and checklist is in place for documentation of what materials were sent to a receiving NTP when a patient is transferred. A training was provided to staff at the scheduled treatment team meeting on 5/18/09 to review the protocols and forms to insure compliance with these procedures. The Pharmacotherapy Coordinator will review the files of the transferred patients to insure the documentation of materials sent to the receiving NTP and thereby insure compliance with this standard |
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 and administrative documentation, the facility failed to provide follow up information for three of four patient records.
The findings include:
Twelve patient records and the follow up folder were reviewed on April 21-23, 2009. Four patient records were reviewed for follow up information. Three patient records did not have follow up information documented, specifically # 4, 6 and 11.
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Plan of Correction
A procedure is in place for documenting follow up information regarding the patient. The Quality Assurance Officer provided a training to the staff person responsible for the execution of this procedure on the morning of 5/18/09 to insure the documentation of patient follow up. The Quality Assurance Officer will then conduct a quarterly review of discharged charts to insure that follow up is being completed within 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 the review of patient records, the facility failed to review, reevaluate, modify and update each patient's treatment plan as required in two of three patient records.
The findings include:
Twelve patient records were reviewed on April 21-23, 2009. Treatment plan updates were required in three patient records.
Patient record # 1 did not have the update information recorded for January 9, 2009 and March 9, 2009; the patient record included a form with the treatment goals listed but there was no documentation of the treatment plan update.
Patient record # 7 contained identical language, word for word, for the updates of January 1 and March 1, 2009.
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Plan of Correction
The Pharmacotherapy Coordinator will provide a training to all Pharmacotherapy Staff on the proper execution of treatment plan updates with specific attention to the requirement to review, re-evaluate, modify and update each patients treatment plan as required by Chapters 157, 709, and 711. The agancy is also part of a research project with the Treatment Research Institute aimed at improving the quality of treatment plans and treatment plan updates. Counselors and Coordinators participated in an 8 hour training from TRI on May 13th to support this initiative.
The Pharmacotherapy Coordinator will continue to maintain quarterly review of clinical records for completeness specific to this plan and agency procedures. |