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 30, 2008 through July 2, 2008 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 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on July 29, 2008.
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Plan of Correction
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715.7(b) LICENSURE Dispensing or Administering Staffing
(b) Dispensing time shall be prorated for patient census. There shall be sufficient dispensing staff to ensure that all patients are medicated within 15 minutes of arrival at the dispensing area.
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Observations
Based on observation during the three day monitoring inspection, the facility failed to ensure that patients are medicated within 15 minutes. The process observed had all patients that had been in group counseling waiting to be medicated with any other patients needing medication being inserted into the patients that were already waiting. The time observed was almost 60 minutes to medicate a patient and complete the process.
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Plan of Correction
The Program Director will Provide oversight with compliance to regulation 715.7(b) by working with the Clinical Supervisor to develop and institute a walk-in medication schedule for patients not scheduled for medication after the group process.
The Program Director will review the regulation pertaining to the deficiency during staff training on 8/4/08. The Program Director will instruct The Clinical, Medical, and Security staff to stop inserting walk-in patients into the group medication process between the hours of 11:00 am to 1:00 pm Monday to Wednesday, and 4:30pm to 6:30pm Tuesday to Thursday.
All patients attending the program will receive a copy of the walk-in medication schedule by their primary Counselor in their group/individual sessions during the week of 8/4/08. The patient will be asked to sign an acknowledgment form documenting the notification of the walk-in medication schedule. The schedule will identify times when walk-in patients may come into the clinic to be medicated that will not interfere with the group medication process.
The program will be in full compliance with standard 715.7(b) on 8/18/08.
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715.16(d)(1-3) LICENSURE Take-home privileges
(d) A narcotic treatment program may make exceptions to the requirements in subsection (c) relating to the length of time of satisfactory adherence to narcotic treatment program rules and number of days of take-home medication when, in the reasonable clinical judgment of the narcotic treatment physician, which is documented in the patient record:
(1) A patient has a permanent physical disability.
(2) A patient has a temporary disability.
(3) A patient has an exceptional circumstance such as illness, personal or family crisis, or travel which interferes with the patient 's ability to conform to the applicable mandatory attendance schedules. In all cases, the patient shall demonstrate an ability to responsibly handle narcotic drugs.
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Observations
Based on review of nineteen patient records, two were reviewed for take-home doses due to exceptional circumstances. The facility failed to document the exceptional circumstance for patient # 4, who was unable to attend the program at the direction of the patient's primary care physician with no further explanation provided.
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Plan of Correction
The Program Director will Provide oversight with compliance of regulation 715.16 (d)(1-3) by reviewing the regulation with the Clinical Supervisor during her weekly supervision session during the week on 8/4/08.
The Program Director will instruct the Clinical Supervisor to document the exceptional circumstance for all patients who are unable to attend the program at the direction of their primary care physician on the appropriate DOH Exception Form.
The form will be completed by the Clinical Supervisor and signed off on by the Program Physician. The Clinical Supervisor will forward the form to the Department of Health for approval via fax. The form will then be forwarded to medical records along with the cover page and transmittal receipt and placed in the patient record by medical records staff. The completion of this task will be monitored by the Program Director as needed during the weekly supervision of the Clinical Supervisor. The program will be in full compliance with standard 715.16(d)(1-3) on 8/18/08. |
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 review of nineteen patient records, four records were reviewed for involuntary termination. Patient #13 was involuntarily terminated for not paying his bill and missing counseling sessions. In addition, the policy and procedure manual was reviewed for compliance with the standards. The facility failed to restrict the policy and procedure on patient termination to the reasons addressed in the regulations. The facility permitted excessive absence, urine testing which indicated illicit drug usage, and failure to seek employment as reasons to terminate the patient from treatment.
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Plan of Correction
The Program Director will Provide oversight with the compliance of regulation 715.21(1)(i-iv) by reviewing the program policies and procedures regarding involuntary terminations with the Clinical/Medical Staff during staff training on 8/4/08. Staff will be instructed to restrict the policy and procedure on patient termination to the reasons addressed in the regulations.
The Clinical Supervisor will be responsible for assigning the Counselor of record the task of assisting patients with financial difficulties with identifying alternative methods of payment until the appropriate funding stream is secured.
The Counselor of record will be responsible for documenting all missed counseling session in the patients record on the day of the occurrence along with an action plan for getting the patient reengaged in treatment services. The program will be in full compliance with standard 715.21(1)(i-iv) on 8/18/08. |
715.22(a) LICENSURE Patient grievance procedures
(a) A narcotic treatment program shall develop and utilize a patient grievance procedure.
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Observations
Based on the review of the facility's grievance log and patient records, the facility failed to follow it's own procedure in investigating and resolving grievances. The facility failed to document what the investigation found or the outcome of the grievance.
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Plan of Correction
The Program Director will provide oversight with the compliance of regulation 715.22(a) by reviewing the program policies and procedures regarding patient grievance procedures with Clinical Staff during staff training on 8/4/08.
Members of the Consumer Satisfaction Committee will be instructed to follow the documented policies and procedures and untilize the existing monthly tracking tools to document the investigatory finding and outcomes of all grievances.
Clinical Supervisor will be responsible for meeting with the Chairperson of the Consumer Satisfaction Committee on a monthly basis to review all patient grievances and assure that the investigatory finding and outcomes have been properly documented.
The program will be in full compliance with standard 715.22(a) on 8/18/08. |
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 nineteen patient records, four records were reviewed for the psychosocial evaluation. Patient # 1 was a re-admitted patient and the facility failed to ensure a new psychosocial evaluation was completed. The facility failed to develop an evaluative assessment of the historical data obtained in two of the four records, patients # 3 and 11. In addition, the evaluation for patient # 8 was completed three months after admission, exceeding the timeframes established for the completion of evaluations.
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Plan of Correction
The Program Director will provide oversight with the compliance of regulation 715.23(b)(15) by reviewing the program policies and procedures regarding patient records and conducting a clinical staff training on 8/4/08.
During the training the Program Director and Clinical Supervisor will provide clinical staff with the appropriate elements and timeframes needed for the completion of psychosocial evaluations for re-admitted and new patients.
The Clinical Supervisor will be responsible for reviewing and documenting the timely completion of all psychosocial evaluations during Counselor of Record weekly supervision session.The program will be in full compliance with standard 715.22(a) on 8/18/08.
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