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 January 5-7, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Addiction Medicine and Health Advocate 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 February 10, 2010.
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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 administrative staff, the facility failed to provide at least one hour per week of physician presence onsite for every ten patients during nine weeks of the four month time period reviewed.
The findings include:
Physician weekly time sheets were reviewed for the time period of September 1, 2009 to December 31, 2009. The licensed capacity for the facility is 450 patients. In discussion with the clinical coordinator, the facility did not go too far below the capacity since it was in effect, and definitely did not go below 400 patients during the time frame reviewed. The facility therefore needed at least 40 hours onsite every week during the time period reviewed.
During the week ending September 6, 2009, the total physician time was documented as 39 hours.
During the week ending September 13, 2009, the total physician time was documented as 21 hours.
During the week ending September 20, 2009, the total physician time was documented as 38 hours.
During the week ending September 6, 2009, the total physician time was documented as 39 hours.
During the week ending October 4, 2009, the total physician time was documented as 38 hours.
During the week ending October 18, 2009, the total physician time was documented as 36 hours.
During the week ending October 25, 2009, the total physician time was documented as 38 hours.
During the week ending November 15, 2009, the total physician time was documented as 36 hours.
During the week ending November 29, 2009, the total physician time was documented as 27 hours.
During the week ending December 27, 2009, the total physician time was documented as 37 hours .
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Plan of Correction
AMHA will ensure onsite physcian coverage as required in the regulation immediately. In the event a regularly scheduled physician is ill, on vaction, or away for reasons beyond his or her control, a back-up physician or appropriate medical professional will be onsite to provide coverage. AMHA will begin recruiting additional physicians, physicians assistants or certified nurse practioners immediately. The Medical Director and Executive Director will be responsible for conformance. |
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 facility for the patient's treatment history in two of two patient records reviewed.
The findings include:
Seventeen patient records were reviewed January 6-7, 2010. Two patient records required contacting the prior treatment facility for the treatment history. Patient records # 5 and 16 did not include documentation of any attempt to obtain the patient's prior treatment history from prior treatment facilities.
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Plan of Correction
The intake counselor has been informed that for any patient applying for treatment at AMHA who may have had previous treatment at another medicated-assisted treatment facility, a written attempt must be made to secure previous treatment records. This will be documented in the patient record. In reviewing intake documentation, the Clinical Coordinator will ensure that these attempts are present with the intake paperwork. The Clinical Coordinator will be responsible for monitoring compliance. We will also monitor compliance via our internal chart review. |
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 provide proper documentation on the consent to release information forms and restrict the information released to what the patient consented to in writing in six of eight patient records reviewed.
The findings include:
Eight patient records were reviewed for completed consent to release information forms and compliance with the confidentiality regulations.
Consent to release information forms documented in patient records # 4, 5 and 6 did not specify what information was to be released.
Consent to release information forms documented in patient records # 9 and 10 did not include documentation of the purpose of the consent to release information.
Consent to release information forms documented in patient record # 1 released more information than was listed on the consent to release information form signed by the patient.
Patient record # 5 included documentation of a release of information that exceeded the limitations imposed at 4 Pa. Code Subsection 255.5(b) regarding releases of information to a patient's probation officer. This information included the patient's bloodwork results, urine drug screen results, physical examination, and progress notes.
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Plan of Correction
AMHA will conduct a staff training to address the four aspects noted as to be deficient. Specifically, the training will explain the proper completion of release of information consent forms. The areas to be be emphasized are: Specific information to be released, the purpose of the release, limitations to releases and full compliance with 4 Pa 255.5(b). The Clinical Coordinator will provide the training and will monitor conformance. We will also review conformace via the internal chart audit process as part of our Quality Improvement Committee. |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on a review of patient records and administrative documentation, the facility failed to ensure that dosage reviews were completed according to program policy and regulation in two of six patient records.
The findings include:
The facility policy and procedure on dosage reviews was reviewed on January 5, 2010. The policy addressing the medication and the physician's dose review stated the procedure was for the counselor to complete a dose review document every six months and submit to the physician for review.
Sixteen patient records were reviewed January 6-7, 2010. Six records required semi annual dosage reviews to be documented. Two patient records did not have dose reviews documented according to regulation or the facility's policy and procedure.
Patient record # 13 was admitted 9-30-2003. The last documented dosage review or dose change was dated 9-24-2008. The dose review prior to that was 1-5-2005.
Patient record # 16 was admitted 12-30-2008. The patient had a dosage review dated 1-7-2009 and the next was 12-18-2009.
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Plan of Correction
AMHA will first revise its policy regarding dosage reviews to reflect our current procedure. Each patient's dosage is reviewed by the physician at the time of their intake and annual physical exam. The physician is then responsible for completing another dosage review within a year, but no sooner than 2 months after the physcial. The Clinical Coordinator will be responsible for ensuring conformace with this policy and procedure. We will also monitor it as part of our internal chart review. |
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 a review of administrative documentation, the facility failed to restrict the reasons for involuntary termination to those reasons allowed by regulation.
The findings include:
Facility policy and procedure on patient termination and the patient handbook were reviewed on January 5, 2010. Policy and procedure stated that the patients may be involuntarily discharged for not following program rules. The patient handbook defines those rule violations as loitering; consuming abusive drugs; coming to clinic high; bringing unauthorized visitors; urinalysis; medication; and take home bottles not secured. This information was located in the patient handbook revised on January 2009.
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Plan of Correction
AMHA will revise its policy and procedure manual as well as the patient handbook to reflect only those reasons listed in the 715 regulations as reasons for involuntary termination. The person responsible for revising the policy will be the Executive Director. The Medical Director will be responsible for monitoring involuntary terminations and conformace with the regulations regarding reason for termination. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on the review of patient records, the facility failed to complete annual physicals or a re-evaluation by the physician in two of five patient records reviewed.
The findings include:
Sixteen patient records were reviewed on January 6-7, 2010. Documentation of annual physical examinations was required in five patient records.
Patient # 13 was admitted on 9-30-2003. The last annual physical exam was dated 10-5-2006.
Patient # 17 was admitted on 11-24-2008. An annual physical exam had not been completed as of January 7, 2010.
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Plan of Correction
AMHA will review its procedure for tracking and scheduling patient physicals. The nurse is currently responsible for scheduling all patients for annual physicals. The Nursing Supervisor will be responsible for reviewing the patient roster to ensure that all patients are scheduled and completed accordingly. The computer system allows for tracking annual physicals and will be more fully utilized as an additional means of monitoring conformance. |
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 facility failed to identify behavioral tasks for the patient to perform to complete each short-term goal in three of six patient records reviewed.
The findings include:
Sixteen patient records were reviewed on January 6-7, 2010. The treatment plans in six patient records were required to include documentation of behavioral tasks to be identified to meet the goal statements.
Patient records # 1, 2 and 14 did not include documentation on the treatment plans to identify behavioral tasks for the patient to complete to meet the identified short term goals.
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Plan of Correction
AMHA has engaged an outside trainer from Philadelphia's Department of Behavioral Health to work individually with counselors in developing behavior-oriented goals and objectives. Additionally, the trainer is working with them to identify behavioral tasks needed to achieve goals and objectives. The training began on 1/25/10 and all counselors are required to participate. The Clinical Coordinator was responsible for setting up this training and for monitoring future comformace. Additional training will be scheduled as needed. |