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 9-11, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Parkside Recovery 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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715.10(c) LICENSURE Pregnant patients
(c) Counseling records and other appropriate patients records shall reflect the nature of prenatal support provided by the narcotic treatment program.
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Observations
Based on the review of patient records, the facility failed to document the nature of pre-natal support in two of four patient records reviewed.
The findings include:
Twenty six patient records were reviewed October 9-11, 2012. Four patient records were reviewed for documentation of prenatal support.
Patient # 16 was admitted February 16, 2012. There were medical notes in regard to prenatal care, but there were no clinical notes of clinical support. Documentation in the patient record identified that the patient continued abusing illicit substances and had been given a letter of termination. The clinical documentation did not address the issues the patient was having pertaining to her continued use of illicit substances.
Patient # 17 had been admitted July 6, 2009. There were medical notes pertaining to prenatal care, but there were no clinical notes of counseling support.
This was discussed with administrative staff who acknowledged the lack of counseling supports for the patients.
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Plan of Correction
All pregnant women will be placed on the same caseload with a counselor who is experienced at working with pregnant opiate dependent women. The counselor will work with the pregnant women through individual and group sessions to ensure pregnancy and recovery issues are addressed. All interventions and counseling notes will be documented through progress notes. The clinical supervisor will be responsible through weekly supervision with the counselor to make sure this deficiency does not re-occur. |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on the review of patient records, the facility failed to transfer the required patient files in two of two patient record.
The findings include:
Twenty six patient records were reviewed October 9-11, 2012. Two patient records required transfer specific patient information to the receiving narcotic treatment program as part of the transfer process. Two patient records did not include the specified information.
Patient # 9 was admitted February 9, 2012 and discharged as a transfer to another narcotic treatment facility June 6, 2012. The documentation of the required patient files being transferred to the receiving facility was restricted to medical and psychosocial summaries and the urinalysis report.
Patient # 10 was admitted March 10, 2010 and discharged as a transfer to another narcotic treatment facility June 8, 2012. There was a fax transmittal receipt showing 5 (five) pages were sent, but there was no documentation that specified what information was sent were to the receiving facility.
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Plan of Correction
Parkside Recovery will transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient according to regulation 715.20. The clinical supervisors will be responsible to receive and audit all transfer packets received from counselors before sending the paperwork to the referred clinic to ensure this deficiency does not re-occur. The Program Director will monitor compliance with the transfer process in weekly supervision with supervisors |
715.20(4) 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.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on the review of patient records, the facility failed to document that it notified the referring facility of the admission and initial dosing of the patient in two of four patient records.
The findings include:
Twenty six patient records were reviewed October 9-11, 2012. Four patient records were reviewed for documentation of the notification to the referring facility of the admission and dosing of the referred patient.
Patient #22 was referred by another narcotic treatment program September 19, 2012 and there was no documentation of the referring facility being notified of the admission and initial dosing of the patient.
Patient #23 was referred by another narcotic treatment program September 10, 2012 and there was no documentation of the referring facility being notified of the admission and initial dosing of the patient.
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Plan of Correction
The Clinical Supervisors will be responsible for sending a letter regarding the referred client's admittance to the program when the client is placed on their counselors caseload. This letter will inform the referring clinic of the client's admission and initial dose date. The Program Director will meet weekly with the clinical supervisors to monitor compliance with this directive and to ensure this deficiency does not re-occur. |
715.22(b) LICENSURE Patient grievance procedures
(b) The procedure shall permit aggrieved patients a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director. If the grievance is filed against the narcotic treatment program director, the review of the case shall be conducted by either a multi-representative group of the narcotic treatment program or a subcommittee of the governing body instituted for the express purposes of grievance adjudication.
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Observations
Based on the review of patient records and discussion with facility staff, the facility failed to demonstrate adherence to the grievance process in providing full and fair procedures to all patients reviewed.
The findings include:
Twenty six patient records were reviewed October 9-11, 2012. The policy and procedure was reviewed October 9, 2012. The grievance documentation was reviewed October 9, 2012 and throughout the monitoring. The policy and procedure reflected compliance with regulation. However, the grievance documentation was not sufficient to determine if the actual procedure was completed as required.
It appears there is only 1 staff involved in the process and there was very minimal information. The procedure stipulated patients wrote their grievance and submitted it to counselor who then forwarded the documentation to their supervisor in charge of the grievances. This supervisor would then address the grievance. The documentation of the results generally only reported that the matter was addressed or the supervisor met with the patient and did not provide any details regarding a resolution.
Patient # 26 submitted a grievance that he had a note from his physician stating he was not to attend groups for 10 weeks due to his surgery. He was required to go anyway or be involuntarily tapered from methadone. When this writer brought this grievance to the attention of the lead clinical supervisor, he acknowledged the incident and stated "I couldn't let him miss groups with his positive urine drug screens." This determination should have been a medical decision and there was no documentation that the medical team was ever notified of this situation.
Patient # 24 and patient # 25 were each admitted to the facility in 2006. Patient # 24 filed a grievance because he alleged he was being transferred to another program because his public funding was no longer available to him. There was no other documentation on the outcome of the grievance.
Patient record # 25 contained documentation the patient had to be transferred because her public funding was no longer in effect and she could not stay as a "self pay." Patient was employed and requested to be able to pay for her treatment. Aside from the counselor stating she could not self pay, there was no other explanation documented in the patient record.
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Plan of Correction
One supervisor will now be in charge of monitoring both incidents and grievances. The supervisor will adhere to the grievance process by following the policy of giving every client a full and fair hearing of the grievance. The supervisor will be responsible to fully document the grievance procedure on a grid and will discuss all grievances weekly in supervision with the Program Director to ensure this deficiency does not re-occur. |