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, for detoxification or maintenance for treatment of of patients dependent on an opioid in a residential facility treatment. This inspection was conducted on July 14, 15. 16 and 17, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Kirkbride Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on August 14, 2008.
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Plan of Correction
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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 review of 10 patient records reviewed for verification of the patient's identity, the facility failed to provide documentation verifying the identity in two of the ten records, specifically patient records # 3 and 9.
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Plan of Correction
1. When accepting referrals from Crisis Response Centers in Philadelphia, the Admissions Department verifies the identity -- name, Social Security number and date of birth -- of each patient verbally. Copies of photo identification, when available, are made part of the admissions packet. The information provided verbally by the patient is compared against the collateral data supplied by the Crisis Response Center to verify the patient's identity. The steps taken to verify the patient's identity are documented on the intake sheets.
2. In the cases of walk-ins who do not have photo identification available, the admission is delayed by the Admissions Department until the patient petitioning for admission is able to produce photographic identification. In such cases, the walk-in patient is referred to the Department of Transportation Center at 11th and Market Streets in Philadelphia to obtain a photo identification; or to the Behavioral Health Services Initiative of Philadelphia for verification of identification.
3. In the case of walk-ins who are suicidal, the Admitting Physician evaluated the patient and makes the appropriate referrals for level of care to ensure patient safety. This may include admission to the acute psychiatric unit.
4. The Director of Admissions will perform chart audits of 10 percent of all Methadone patients monthly to four months to ensure compliance with the above-stated procedures. Results will be reported monthly to the Executive Committee for oversight and monitoring. |
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 the review of 10 patient records, eight were reviewed to verify that the physician conducted a face to face determination of dependency for each patient. Of the eight records reviewed, four failed to document the justification for the determination of dependency. Record #1 listed the patient statement and having a treatment history on file, but the record contained the notation of the patient having recently been in a detoxification unit only. Records # 2 and 4 contained the patient statements only; and # 3 listed patient's prior treatment at a pain clinic.
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Plan of Correction
1. The Medical Director of the Methadone Program, during the next quarterly meeting of the Medical Staff on September 25, 2008, will review with all physicians the requirement that the justification for a determination of dependency be included in the psychiatric admission note.
2. The Medical Director will develop guidelines for physicians who perform evaluations of prospective Methadone patients.
3. Following the training by the Medical Director, the Clinical Director will perform chart audits of 10 percent of open Methadone charts on a single day each month for three months.
4. Results of the audits will be reported to the Executive Committee for oversight and monitoring. Results also will be reported to the Medical Staff Organization during its quarterly meeting on December 6, 2008. |
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 10 patient records, 8 records were reviewed for the complete initial urinalysis. The facility failed to obtain a complete urine drug screen prior to the administration of methadone, a narcotic agent in 5 of the 8 patient records #1, 2, 3, 4 and 6. A complete urine drug screen includes receiving the results from the CLIA and Department of Health approved laboratory.
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Plan of Correction
1. The facility currently possesses a laboratory license from the Pennsylvania Department of Health, Bureau of Laboratories, which is valid through August 15, 2009. The license was required because the facility uses waived tests, but does not have an on-site laboratory. Instead, all samples are sent to Princeton Laboratories Inc. for analysis. The facility has signed up with the state for competency testing in which quarterly blind samples are sent to the facility, tests are completed and the test results are sent back to the state for analysis. In addition, as part of the facility's JCAHO accreditation, managers have developed competency tests for all employees who perform waived tests, including those for urinalysis. Staff must successfully complete the competency, given annually, before they are authorized to perform waived testing such as urinalysis.
2. In establishing physiological dependence in newly admitted patients, physicians sign an attestation of opiate addiction, which includes establishment of a one-year history of dependence.The program is residential and is staffed by Narcotic Treatment Physicians and nurses 24 hours daily. A Narcotic Treatment Physician is on-site during off-hours and on weekends. In addition, all the residential units are staffed round-the-clock by a nurse to observe any problems with the initiation of Methadone.
3. Although the facility utilizes instant urine drug screens that are CLIA-waived at the time of admission, the sample is sent to Princeton Laboratory for processing.
3. In some cases, the Admissions Department is able to receive laboratory results from Crisis Response Centers prior to the admission being accepted. However, those laboratory results are not always from a CLIA- and Department of Health-approved laboratory and often are instant tests.
4. The facility will seek a special expection for the process from the Bureau of Drug and Alcohol Programs to permit the establishment of opiate addiction by the admitting physician, the continued use of CLIA-waived instant drug screens and the administration of narcotic agents prior to receipt of the drug screen results from Princeton Laboratories.
5. The facility accepts for care those individuals who are severely sick or in the throes of withdrawal and the philosophy of the program is to successfully treat patients in withdrawal as quickly as possible. To do otherwise, would result in an increase in AWOLs and AMAs. All patients admitted to the residential program and detox programs are assessed by a Medical Doctor, who determines both level of care and initiates Physician Orders, including orders for Methadone. By protocol, a low dose of Methadone is provided until the faciity receives laboratory results. However, the lab results can take up to 48 hours. Using best practices and strong clinical judgment, the Narcotic Treatment Physicians utilize best available evidence and collateral to make a determination about the administration of Methadone.
6. All Methadone orders for new patients are reviewed by the Medical Director.
6. Because of the measures indicated above, the facility is attempting to meet the spirit, if not the intent, of the regulation. |
715.22(c) LICENSURE Patient grievance procedures
(c) Penalties may not be initiated prior to final resolution with the exception that penalties may be initiated against patients who have committed acts of physical violence or who have threatened to commit acts of physical violence in or around the narcotic treatment program premises.
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Observations
Based on the review of the administrative documentation of administrative detoxifications, grievances and 2 patient records, the facility failed to ensure the administrative detoxification was suspended when the patient submitted a written appeal, but rather continued with the involuntary detox and subsequent discharge without addressing the grievance appeal in one patient record, # 11.
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Plan of Correction
1. The facility will ensure that patients placed on administrative detox for an infraction of rules of conduct will be afforded the opportunity to appeal in writing his/her placement on administrative detox.
2. The program's policy and procedure governing administrative detox will be amended to ensure that administrative detoxes are suspended upon the patient's filing of a written appeal to the administrative detox.
3. The policy will require that the appeal be considered by the Medical Director, the Project Director, the Facility Director and the Clinical Supervisor(s) within 24 hours of its initiation. During the time the written appeal is being considered, the administrative detox will be suspended and the patient's Methadone dose will be reviewed and adjusted as necessary by the Medical Director or Attending Physician.
4. The decision of the Medical Director, Project Director, Facility Director and Clinical Supervisor(s) hearing the appeal will be considered final for the purpose of resuming or overturning the administrative detox. |
715.23(b)(11) LICENSURE Patient records
(b) Each patient file shall include the following information:
(11) Counselor notes regarding patient progress and status.
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Observations
Based on review of 11 patient records, the facility failed to provide the required information regarding the patient's progress and status in the clinical notes in 8 of the 11 records reviewed, # 2, 3, 4, 5, 8 and 9. The Data, Assessment, Plan (DAP) format was utilized. The "A" (assessment) failed to consistently provide a clinical assessment of the patient's progress in both the individual and group therapy sessions. The group sessions did not contain information on the topic of the group or group dynamics.
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Plan of Correction
1. The Clinical Operations Supervisor and the Clinical Director will review the group note template and make adjustments as necessary to ensure qualitative assessments are part of group interactions.In addition, group topic will be more clearly delineated to ensure greater clarity to the group note documentation.
2. Staff will be re-trained in the DAP note format, with special attention paid to the assessment portion of the notes to ensure this section of the DAP notes includes an evaluative assessment.
3. The program will continue to participate in case conceptualization trainings at an external agency noted for its research into and development of Cognitive Therapy.
4. After the group note template has been revised, staff will be trained in its application and expectations of qualitative evaluations will be emphasized.
5. The Clinical Operations Supervisor and the Clinical Director will monitor charts monthly on an ongoing basis. One-on-one remediation will be provided to clinicians, as necessary. |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on review of 11 patient records, the facility failed to provide an evaluative assessment of the historical data obtained that included the counselor's clinical analysis of the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, patient's attitude toward treatment and overall impressions. Instead, the psychosocial evaluations of the patient consisted primarily of the repetition of the history and statements reported by the patient in 5 of the 11 records reviewed, # 1, 2, 3, 4 and 7. In addition, # 9 was illegible and # 5 had an evaluation from a prior admission.
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Plan of Correction
1. Beginning in April 2007, the program launched a concerted effort to improve the quality of the biopsychosocial narratives, which essentially function as a case conceptualization.
2. To that end, the facility sponsored a two-hour training for clinicians in case conceptualizations presented by an adjunct professor of cognitive therapy at the Philadelphia College of Osteopathic Medicine.
3. Beginning in October 2007, the program began facilitating clinicians to attend live case conceptualization trainings at the Institute for Cognitive Therapy. There, clinicians have been educated by Aaron T. Beck, MD, considered the father of cognitive therapy. Participation in the live case conceptualization trainings has been ongoing since that time with clinicians attending about six times each year.
4. Following an on-site inspection by a surveyor from the Joint Commission on the Accreditation of Healthcare Organizations on February 22, 2008, the Clinical Operations Supervisor and the Director of Social Services revised the biopsychosocial format to provide greater attending to three key areas of assessment: spirituality, leisure activities and relapse history.
5. The Executive Director provided a training in the new assessments as well as an overview of case conceptualizations for clinicians on March 24, 2008.
6. Since that time, the quality of the assessments has been monitored in order to improve the quality of the evaluations and to ensure that the assessments do not represent a recap of demographic information that is covered in the biopsychosocial.
7. The Executive Director will monitor the quality of the assessments monthly for four months with results reported to the Executive Committee for oversight and monitoring.
8. One-to-one and group remediation to improve the evaluative quality of assessments will continue as a result of the chart audits. The weekly one-to-one and group supervision sessions will be used to continually monitor the quality of the assessments. The supervision sessions are led by the Facility Director, the Clinical Director and the Clinical Operations Supervisor.
9. Qualitative progress is expected to be observed within three months. |
715.23(d) 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.
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Observations
Based on the review of 11 patient records, 9 were reviewed for the content of the treatment plan. The treatment plans contained global and non-specific goals; the contents did not address patient specific needs and goals as identified in patients' personal histories and psychosocial evaluations in 8 patient records, specifically # 1, 2, 3, 4, 6, 7, 8 and 9.
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Plan of Correction
1. The updated treatment plan template was revised by the Clinical Operations Supervisor in the spring of 2008.
2. The Clinical Operations Supervisor and the Clinical Director will provide a training for clinicians in how to incorporate specific patients needs as identified in the biopsychosocial and narrative into the treatment plan.
3. Following the training, the Clinical Operations Supervisor and the Clinical Director will perform chart audits of 10 percent of open medical records on a single day during the second week of each month for 12 months.
4. Results of the audits will be reported to the Executive Committee monthly for 12 months for oversight and monitoring. |
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 11 patient records, 9 were reviewed for the content of the treatment plan. The facility failed to ensure behavioral tasks to complete the goals were identified. Rather, the treatment plans contained global objectives in 8 patient records, specifically # 1, 2, 3, 4, 6, 7, 8 and 9.
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Plan of Correction
1. The updated treatment plan template was revised by the Clinical Operations Supervisor in the spring of 2008.
2. The Clinical Operations Supervisor and the Clinical Director will provide a training for clinicians in how to develop behavioral tasks in the treatment plan to ensure that the behavioral tasks move the patient toward completion of treatment goals.
3. Following the training, the Clinical Operations Supervisor and the Clinical Director will perform chart audits of 10 percent of open medical records on a single day during the second week of each month for 12 months.
4. Results of the audits will be reported to the Executive Committee monthly for 12 months for oversight and monitoring. |
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 11 patient records, 9 were reviewed for the content of the treatment plan update. The facility failed to document the progress or lack of progress in achieving the goals from the prior treatment plan in 5 of the 9 patient records # 1, 3, 4, 6 and 8. Instead, there was a general statement of overall progress in treatment and new goals without explanation as to whether the original goals were resolved or why the new goals were developed.
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Plan of Correction
1. The updated treatment plan template was revised by the Clinical Operations Supervisor in the spring of 2008.
2. The Clinical Operations Supervisor and the Clinical Director will provide a training for clinicians in documenting progress or lack of progress on treatment goals and objectives and incorporating the assessment of progress on treatment goals and objectives in updated treatment plans.
3. Following the training, the Clinical Operations Supervisor and the Clinical Director will perform chart audits of 10 percent of open medical records on a single day during the second week of each month for 12 months.
4. Results of the audits will be reported to the Executive Committee monthly for 12 months for oversight and monitoring. |