INITIAL COMMENTS
|
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 September 21 through September 23, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, A. R.S. of Lancaster, LP 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
|
Plan of Correction
|
715.6(a)(3)(ii) LICENSURE Physician staffing
(a) A narcotic treatment program shall designate a medical director to assume responsibility for administering all medical services performed by the narcotic treatment program.
(3) The medical director 's responsibilities include the following:
(ii) Supervision of licensed practical nurses if the narcotic treatment program does not employ a registered nurse to supervise the nursing staff. In addition, the medical director in these instances shall ensure that licensed practical nurses adhere to written protocols for dispensing and administration of medication.
|
Observations
The facility failed to ensure that the licensed practical nurse (Director of Nursing) received supervision from the Medical Director.
The findings include:
Personnel records were reviewed on September 21 and 22, 2009. The job description of the the medical director failed to include supervision of the nursing staff as one of his responsibilities. During an interview with the Executive Director on September 22, 2009 at 9:25 a.m. it was reported that the Executive Director supervised the Director of Nursing/LPN.
|
Plan of Correction
The ARS Medical Director will provide supervision immediately to all ARS LPN staff and additionally has signed a revised job description to include supervision of Licences Practical Nurses if the NTP does not employ a RN to supervise the nursing staff. In addition, the ARS Medical Director in these instances shall ensure that LPN's adhere to written protocols for dispensing and administration of medication.
The ARS Medical Director will conduct weekly supervision of all LPN's effective immediately. The ARS Medical Director will also conduct a monthly medical team meeting in which supervision is provided for all medical personnel including LPN's, the ARS Nurse practitioner, and ARS Physician.
ARS Medical Director is responcible to ensure supervision of all LPN's occur each week. |
715.8(1)(vi) LICENSURE Psychosocial Staffing
A narcotic treatment program shall comply with the following staffing ratios as established in Chapter 704 (relating to staffing requirements for drug and alcohol treatment activities):
(vi) Outpatients. The counseling caseload for one FTE counselor in an outpatient narcotic treatment program may not exceed 35 active patients.
|
Observations
Based on a review of the counseling caseloads the facility exceeded the 35 active patients per counseling caseload for one FTE counselor.
The findings include:
Based on a review of counselor caseloads presented by the Executive Director on September 21, 2009, the facility exceeded the counseling caseload of one full-time equivalent (FTE) counselor for every 35 active patients. Employee #1 had a 40:1 ratio.
|
Plan of Correction
The ARS Executive Director/Designee will ensure all FTE counselors caseloads will not exceed 35 active patients.
Over the next 6 months, ARS Executive Director will assign all new patients to the FTE ARS counseling staff and ensure all FTE counseling staff caseload will not exceed 35 active patients.
In addition, ARS Executive Director will review the ARS methasoft system daily under counselor caseload assignment and ensure all ARS FTE counseling staff active caseload will not exceed 35 active patients.
After 6 months, ARS Executive Director will then randomly review the ARS Methasoft system counselor caseload assignment to ensure compliance is met. |
715.9(a)(1) 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:
(1) Verify that the individual has reached 18 years of age.
|
Observations
Based on the review of 32 patient records, the facility failed to provide documentation that verified the patient had reached the age of 18 in three of eleven patient records reviewed.
The findings include:
On September 21, 2009 the facility policy and procedure manual was reviewed. According to the facility's policy and procedures they will verify the patient's identity by having a copy of a driver's license, passport or another type of valid identification. The facility failed to provide documentation verifying the individual's age in three of eleven records, specifically patient records #1, 3 and 7.
|
Plan of Correction
ARS Executive Director/Designee for the next 6 months will review all admission charts to ensure verification is provided verifying each new patients name, address, date of birth, and other identifying data via a copy of their drivers license, passport, or another type of valid identification prior to administration of an agent.
ARS Executive Director in conjuction with the ARS counseling staff will conduct chart audits on all active patients to ensure each patient has proper identification in each chart.
After 6 months, ARS Executive Director/Designee will then conduct random chart audits to ensure compliance is met. |
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.
|
Observations
Based on the review of 32 patient records, the facility failed to provide documentation that verified each individual's identity to include name, address, and date of birth in three of eleven patient records.
The findings include:
On September 21, 2009 the facility policy and procedure manual was reviewed. According to the facility's policy and procedures they will verify the client's identity by having a copy of a driver's license, passport or another type of valid identification. Based on review of eleven patient records, the facility failed to follow their policy. The facility failed to provide documentation that verified an individual's identity in three of eleven records, specifically patient records #1, 3 and 7.
|
Plan of Correction
The ARS Executive Director/Designee over the next 6 months will review all admission charts to ensure verification is provided verifying each new patients name, address, date of birth, emergency contact, and other identifying data via a copy of their driver's license, passport, or another type of valid identification prior to the administration of an agent.
ARS Executive Director in conjunction with the ARS counseling staff will conduct chart audits of all current patients to ensure compliance is met.
After 6 months, ARS Executive Director will then conduct random chart audits to ensure compliance is met |
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.
|
Observations
Based on a review of thirty-two patient records on September 21 through 23, 2009, the narcotic treatment program failed to have a narcotic treatment physician make a face-to face determination and document in the patient's record the basis for determining an individual's physiological dependence upon a narcotic drug in 3 of 14 records, as required.
Findings:
In patient record # 7, the documentation indicated the determination of current physiological dependence was the patient's statement and the positive urine drug screen. The was no reference to information provided in the patient record that provided specific information regarding the patient's current physiological dependence..
In patient record #10 the documentation indicated drug related arrests as the determination of whether or not the patient was currently physiologically dependent upon a narcotic drug; however, nothing in the patient record substantiated this claim.
In patient record #19 the doctor failed to document the patient had a current dependency.
|
Plan of Correction
The ARS Executive Director/Designee, over the next 6 months, will review all new patient admission charts to ensure prior to administration of an agent, that the ARS Medical Director or ARS treatment physician has made a face to face determination of whether an individual is currently phsiologically dependent for at least 1 year. ARS Medical Director/ARS Physician shall document in the patients record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
ARS Medical Director/ARS Physician will provide information in the patients record regarding the patients current physiological dependency, not just a patient statement and positive drug screen and if drug related arrests are given as a determination of dependence documentation of this will be provided in the patient record.
After 6 months, ARS Executive Director/Designee will then conduct random chart audits to ensure compliance is met. |
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.
|
Observations
Based on a review of thirty-two patient records on September 21 through 23, 2009, the facility failed to obtain the required patient consent to contact the previous facility for the treatment history. The narcotic treatment program failed to document this in three of five patient records.
Findings:
Patient records # 7, 8, and 13 each reported prior history of narcotic program treatment. The facility failed to document that they attempted to obtain the patient's consent to contact the previous facility for the treatment history for patient records # 7, 8, and 13.
|
Plan of Correction
ARS Executive Director/Designee, for the next 6 months, will review all admission charts and ensure contact is made to previous NTP programs all new patient admissions had been previously discharged form to obtain patient treatment history.
In addition, ARS Executive Director/Designee will ensure patient consent is received and documented in the patient records.
ARS Director/Designee will then conduct random chart audits, after 6 months, to ensure compliance is met. |
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).
|
Observations
Based on a review of patient records on September 21 through 23, 2009, the facility failed to maintain confidentiality of patient records in accordance with 42 CFR 2.22 and in one of thirty-two records.
The findings include:
Patient record #19 signed a consent to release information on 7/30/2009 for the release of urine drug screen results to be provided to a housing authority. Additionally, patient record # 19 failed to contain documentation of a release of information to another methadone clinic;
the patient record contained documentation of information provided to another methadone facility for the purpose of transfer but there was no release documented in the patient record to permit this disclosure.
|
Plan of Correction
ARS Executive Director/Designee will conduct a training on 42 CFR 2.22 (relating to confidentiality) and completion of releases of information for all staff by October 31, 2009.
In addition, ARS Executive Director will review all admission charts for the next 6 months to ensure all proper consents/releases of information are obtained and executed properly. After 6 months, Executive Director will then randomly review charts to ensure all proper consents/releases of information are obtained and executed properly.
|
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
|
Observations
Based on the review of patient records, the facility failed to ensure the patient signed the informed consent prior to the administration of a narcotic agent in one of twelve patient records reviewed.
The findings include:
Thirty-two patient records were reviewed on September 21 through September 23, 2009. Informed consent documentation was required in twelve patient records. Patient # 29 was discharged from the program on 7/20/2009 and readmitted Patient # 29 on 8/19/2009. The facility failed to document that the patient signed a consent for treatment at the time of readmission.
|
Plan of Correction
Over the next 6 months, The ARS Executive Director/Designee will review all new admission charts to ensure a signed informed, voluntary, written consent is obtained before an agent is administered to all new patients.
After 6 months, ARS Executive Director/Designee will then conduct random chart audits of all admission charts to ensure compliance is met. |
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.
|
Observations
Based on a review of thirty-two patient records on September 21 through 23, 2009, the facility failed to ensure the completion of random drug-screening urinalysis at least monthly in one record. The facility also failed to obtain urine results prior to the initial dose in three of eleven patient records.
The findings include:
Based on the review of patient records the facility failed to obtain urine drug screen results in three patient records.
Patient #19 was dosed on 3/10/2009. The patient record indicated the results for patient #19 were not received until 3/11/2009.
Patient # 12 received an initial dose of methadone on 5/26/2009. The patient record indicated that the facility did not receive any drug-screening urinalysis results for patient #12 until 5/27/2009.
Patient #29 was discharged on 7/20/2009 and readmitted to the program on 8/19/2009. The patient record failed to provide documentation of a drug screen urinalysis prior to readmission. Further there was not documentation of any drug-screening urinalysis results during the month of August.
Patient record #29 did not have any documentation of results for a monthly urine screen in June and August 2009. An interview with employee # 16 on September 23, 2009 confirmed that the facility did not have any urine drug-screening urinalysis results for June or August for patient #29.
|
Plan of Correction
ARS Executive Director/Designee will review all admission charts for the next 6 months to ensure an initial drug screen urinalysis for each new admission is performed and documented in their patient chart prior to the administration of an agent.
Over the next 6 months, ARS Director/Designee will also ensure all current patients have a random urinalysis of at least monthly documented in their patient charts.
In addition, ARS Executive Director will review the ARS Methasoft System each month, which tracks each patients urinalysis performed, and will ensure each patient had at least one random urinalysis performed for each month and it is documented in their patient chart.
ARS Executive Director will then conduct random chart audits thereafter to ensure compliance is met. |
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.
|
Observations
Based on a review of thirty-two patient records on September 21 through 23, 2009, thirteen were required to have documentation that the narcotic treatment physician reviewed the dosage levels at least twice a year, with each review occurring at least 2 months apart. The narcotic treatment program failed to document the physician's dosage review in one of nine patient records.
Findings:
Patient record #17 was admitted on 5/6/2006. The narcotic treatment physician last conducted a dosage review on 4/17/2009. There was no additional medication review since 5/17/2008.
|
Plan of Correction
ARS Medical Director/Physician will review doseage levels for all patients at least twice per year, with each review occuring at least 2 months apart, to determine a patients therapeutic dosage. The ARS Medical Director/Physician will use the ARS Methasoft System to track each patient and ensure all patients are in compliance. In addition, ARS Executive Director/Designee will conduct chart audits over the next 6 months for %25 of all patient records and ensure compliance is met.
ARS Executive Director will then conduct random chart audits thereafter for compliance. |
715.16(b)(1-8) LICENSURE Take-home privileges
(b) The narcotic treatment physician shall consider the following in determining whether, in exercising reasonable clinical judgment, a patient is responsible in handling narcotic drugs:
(1) Absence of recent abuse of drugs (narcotic or non-narcotic), including alcohol.
(2) Regular narcotic treatment program attendance.
(3) Absence of serious behavioral problems at the narcotic treatment program.
(4) Absence of known recent criminal activity.
(5) Stability of the patient 's home environment and social relationships.
(6) Length of time in comprehensive maintenance treatment.
(7) Assurance that take-home medication can be safely stored within the patient 's home.
(8) Whether the rehabilitative benefit to the patient derived from decreasing the frequency of attendance outweighs the potential risks of drug diversion.
|
Observations
Based upon record review and observation, the facility failed to ensure the physician rescinded the take-home medication privilege in three patient records that were reviewed.
The findings include:
Based on review of patient records on September 21 through September 23, 2009, the facility failed to address rescinding take-home privileges in three patient records.
Patient #9 reported an arrest during a group session but there was no further documentation in the patient record to address this arrest. There was no documentation of any reconsideration of patient's take home status in the patient's record and the patient continued to have take home privileges.
According to patient record documentation, patient #19 reported to the facility five times a week for dosing. Patient # 19 tested positive for illicit drug use in 7/09 and 8/09. The facility failed to document the rationale for the patient's take home privileges.
Patient # 3 was admitted on 5/20/2009. The patient tested positive for illicit drug use in 5/09, 6/09, 7/09 and then was placed on a behavioral contract in 8/09. The patient was provided take-home privileges in September 2009. The facility failed to consider the eight point criteria when making this determination as the patient's recent illict drug use would have to have been included in the consideration for take-home privileges.
|
Plan of Correction
ARS Executive Director/Designee will conduct an all staff training by October 31, 2009 on the 8 point criteria necessary for determining if a patient is responcible in handling narcotic drugs for take home doses.
In addition, all current patients receiving take home doses will be reviewed for compliance of the 8 point criteria by the ARS counseling staff immediately after the staff training and those patients not in compliance will be presented to the ARS Medical Director for review and possible removal of take home doses.
Over the next 6 months, ARS Executive Director will review all take home requests with the ARS counseling staff prior to presentation to the ARS Medical Director to ensure each patient meets the 8 point criteria.
After 6 months, ARS Executive Director will then review all take home requests with the counseling staff randomly to ensure compliance is met. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
|
Observations
Based on a review of patient records on September 21 through 23, 2009, the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment in two of fifteen records.
The findings include:
Based on the review of 32 patient records, 15 were reviewed for psychotherapy hours. The facility failed to provide the required 2.5 hours of psychotherapy in patient records # 21 and 12.
Patient record # 21 contained documentation of 2.5 hours in 7/09, 1 hour in 8/09 and 2.5 hours in September for an average of 2 hours per month.
Patient record # 12 provided psychotherapy documentation to include 1 hour in 6/09, 0 hours in 7/09 and 1 hour in 8/09 for an average of .67 hours of psychotherapy per month.
|
Plan of Correction
ARS Executive Director/Designee, for the next 6 months, will review with each counselor their entire caseload and ensure that each patient received and it is documented in their patient chart a minimum of 2.5 hours of psychotherapy per month, and that 1 hour of that each month is individual psychotherapy, during the patient's first 2 years in treatment.
ARS Counselors will place stops on patient's the last week of the month to ensure all patient's who are non compliant with counseling hours are met with and meet thier counseling compliance for each month.
ARS Executive Director will then conduct random chart audits after 6 months to ensure compliance is met. |
715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
|
Observations
Based on review of client records, the facility failed to provide adequate pyschotherapy services to the patient during the third and fourth year of treatment to one of two patients.
The findings include:
Based on the review of 32 patient records on September 21-23, 2009, two records were reviewed for psychotherapy hours during the third and fourth year of treatment. Patient #17 was admitted on 5/16/2006. This patient received 0 hours of therapy in 7/09, 0 hours in 8/09 and 1 hour in 9/09.
|
Plan of Correction
ARS Executive Director/Designee, over the next 6 months, will review with each counselor their entire caseload and ensure that each patient received and it is documented in their patient chart a minimum of 1 hour of psychotherapy for all patients who are in their 3rd and fouth year of treatment.
ARS Counselors will place holds on patient's on the last week of the month that are non compliant with hours and meet with them to ensure they meet counseling compliance for the month.
ARS Executive Director will then conduct random chart audits to ensure compliance is met. |
715.20(2) 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.
(2) A narcotic treatment program shall maintain the confidentiality of patient records remaining in its possession after the transfer under § 715.11 (relating to confidentiality of patient records).
|
Observations
Based on a review of patient records, the facility failed to provide documentation of the information that was forwarded to the narcotic treatment program in one of one patient records reviewed.
The findings include:
Based on the review of patient records reviewed on September 21, through 23, 2009 one patient record was reviewed for compliance with the transfer process from one methadone facility to another. Patient record # 13 was admitted on 7/9/2009. The patient record indicated that patient # 13 was transferred to another methadone facility on 9/8/2009. The facility failed to document the information that was provided to the facility.
|
Plan of Correction
ARS Executive Director/Designee, over the next 6 months, will review all transfers to/from another NTP for continued maintenance, detoxification, or another treatment activity and ensure that the transfers occur within 7 days of the request and is documented in the patient record. ARS will also maintain confidentiality of patient records remaining in our possession after the transfer under 715.11 (relating to confidentiality of patient records). ARS Executive Director will also ensure all information provided to/from transferred facillities is retained in the patient record.
After 6 months, ARS Executive Director will conduct random chart audits to ensure compliance is met. |
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.
|
Observations
Based on a review of 32 patient records on September 21 through 23, 2009, the narcotic treatment program failed to document, in writing, that it notified the transferring narcotic treatment program of the admission of the patient and the initial dose given in three of four records, as required.
Findings
During a review of patient records #2, 9, and 13, there was no documentation in the record that the narcotic treatment program notified the transferring narcotic treatment program of the patient's admission and initial dose. This documentation was not presented during the on-site monitoring.
|
Plan of Correction
ARS Executive Director/Designee over the next 6 months will review all patient transfers to/and from another NTP for continued maintnenance, detoxiifcation, or another treatment activity and ensure their is documentation in writing that ARS has notified the transferring NTP of admission of the patient and the initial dose given within 7 days of the patients request and it is documented in the patient chart.
After 6 months, The ARS Executive Director/Designee will then conduct random chart audits to ensure compliance is met. |
715.21 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.
|
Observations
Based on the review of client records the facility failed to follow policy and procedure to notify the patient of an involuntary discharge in three of three patient records.
The findings include:
Based on the review of patient records on September 21 through 23, 2009, the facility failed to document in writing that a patient was being involuntarily discharged in patient records # 23, 27 and 31.
|
Plan of Correction
ARS Executive Director will review all patients that are presented for involuntary discharge for the next 6 months and ensure that every effort to retain the patient in treatment have failed prior to initiating the involuntary discharge process. ARS Executive Director will also ensure that all patients presented for involuntary discharge are notified in writing of the discharge and why they are being discharged, offered an opportunity to have a fair hearing, and if not satisfied with the fair hearing results given the opportunity to appeal the decision of the hearing.
ARS Executive Director will then review each case with the ARS Medical Director prior to presentation for involuntary discharge and ensure all procedures have been followed.
After 6 months, ARS Executive/Designee wil then conduct random chart audits to ensure compliance is met. |
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.
|
Observations
Based on the review of patient records, the narcotic treatment program failed to document the results of annual reevaluations by the narcotic treatment physician in 3 of 3 patient records.
The findings include:
Thirty- two patient records were reviewed on September 21 through 23, 2009. Annual reevaluations by the narcotic treatment physician were required in 3 patient records. The narcotic treatment program failed to have the documentation indicating that the narcotic treatment physician reevaluated the patient in patient record # 5, 18 and 21.
|
Plan of Correction
ARS Executive Director/Designee will review the ARS Methasoft System's Annual Physicals/re-evalualuations Due Report each month for the next 6 months to ensure all annual physicals/re-evaluations are completed. ARS Executive Director/Designee will then conduct chart audits of all patients whose annual physical/re-evaluation is due for the month and ensure compliance is met.
ARS Executive Director/Designee will meet with ARS Medical Director/treatment physician regarding any non compliant patients and ensure an annual physical/re-evaluation is completed within 7 days.
ARS Executive Director/Designee will then conduct random chart audits thereafter, to ensure compliance is met. |
715.23(b)(11) LICENSURE Patient records
(b) Each patient file shall include the following information:
(11) Counselor notes regarding patient progress and status.
|
Observations
Based on the review of thirty-two patient records, the narcotic treatment program failed to document progress notes in two of ten patient records. Additionally, the facility failed to document individualized assessments and plans in group notes in seven of ten records.
The findings include:
Thirty-two patient records were reviewed on September 21-23, 2009. Ten records reviewed required progress and group notes.
In patient records #1 and 7 the group notes had general, non-specific assessments of the client.
In patient record # 2 the clinician had late individual notes on 7/1/2009 and 7/8/2009. The patient record of services identified the patient had individual sessions on 8/9/2009 and 8/15/2009 but there were no progress notes that pertained to these contacts in the patient record.
|
Plan of Correction
ARS Executive Director/Designee, over the next 6 months, will audit at a minimum 10% of all of the ARS Counselors charts to ensure each patients charts includes counselor's progress and group notes for each session and group completed and it matches the patient's record of service.
ARS Executive Director will also ensure each group note provides individualized assessments and plans and is documented in the patient's chart.
ARS Executive Director/Designee will then conduct random chart audits, thereafter, to ensure compliance is met.
|
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
|
Observations
Based on the review of patient records and administrative documentation, the facility failed to complete psychosocial evaluations within thirty days of admission in seven of fourteen records.
The findings include:
Thirty-two patient records were reviewed on September 21 through 23, 2009. Fourteen patient records were reviewed for psychosocial evaluations.
Patient record # 11 was admitted June 18, 2009. The facility failed to document a psychosocial evaluation in record # 11.
Patient records # 1, 3, 7, 12, 13, and 19 had psychosocial evaluations; however, the clinicians had documented data driven information that was a repeat history of patient report and did not include a clinical assessment.
|
Plan of Correction
ARS Executive Director/Designee, for the next 6 months, will review all new patient admission charts to ensure all of the patient's records contain a completed psychosocial evaluation of the patient within 30 days of admission into the program.
ARS Executive Director will also ensure all psychosocial evaluations include a clinical assessment of each patient, not just data driven information that is just a repeat history of what the patient reported.
After 6 months, ARS Executive Director/Designee will then conduct random chart audits thereafter, to ensure compliance is met. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
|
Observations
Based on review of patient records, the facility failed to provide follow-up services to 7 of 9 patient records reviewed.
The findings include:
Thirty-two patient records were reviewed on September 21 through 23, 2009. Nine patient records reviewed required follow-up services. Patient records # 11, 23, 24, 25, 26, 27, and 28 had undated follow-up letters contained in their records with a signature from the clinician in ink. There was no documentation in the patient records that provided confirmation that the letteres had been sent.
|
Plan of Correction
ARS Executive Director/Designee, over the next 6 months, will review all discharged patient's charts and ensure follow up services are provided within 7 days of discharge and documented in the patient's chart.
ARS Executive Director will ensure all follow up letters are dated and have an ARS Clinician's signature on them and their is confirmation that the letter's have been sent documented in the patient record.
After 6 months, ARS Executive Director/Designee will then conduct random chart audits, thereafter, to ensure compliance is met. |
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.
|
Observations
Based on the review of patient records, the narcotic treatment program failed to document complete treatment plans in six of thirteen patient records.
The findings include:
Thirty-two patient records were reviewed on September 21 through 23, 2009. Treatment plans were required in thirteen patient records. The narcotic treatment program did not document support services in the treatment plan in patient records # 3, 4, 6, 7, 19, and 21.
|
Plan of Correction
ARS Executive Director/Designee, over the next 6 months, will review at a minimum 10% of all ARS Clinician charts to ensure all treatment plans are outlining realistic short term and long term goals that are mutually acceptable to the patient and ARS. In addition, ARS Executive Director/Designee will ensure support services are documented in treatment plans. ARS Executive Director will review the local resource directory and forward a copy of it to all staff to use as a guide for support services that are located in the community.
ARS Executive Director will then conduct random chart audits, after 6 months, to ensure compliance is met. |
715.29(4) LICENSURE Exceptions
A narcotic treatment program is permitted, at the time of application or any time thereafter, to request an exception from a specific regulation.
(4) The narcotic treatment program shall maintain documentation of the Department 's approval of an exception.
|
Observations
Based on the review of patient records the facility failed to follow the Department's specification on call backs for patients that have exceptions for take home privileges in one of one patient records.
The findings include:
Thirty-two patient records were reviewed on September 21 through 23, 2009. One patient record had an exception for take home privileges. Patient #32 had a 13 day take home exception that was approved by the Department. Requirements of this exception include quarterly call backs. On 9/18/2009, documentation in patient record #32 identified the patient was telephoned and instructed to return to the facility with her take home bottles. Prior to this event the last call back for this patient occurred on 5/6/2008.
|
Plan of Correction
ARS Executive Director/Designee, over the next 6 months, will ensure that ARS will maintain documentation of the Department's approval of an exception, specifically, ensuring call backs for patient's that have an exception occur at a minimum on a quarterly basis and are documented in each patient's chart.
ARS Executive Director/Designee will review all patient charts that have exceptions each quarter to ensure call backs have been performed and documented in each patient's chart.
ARS Executive Director/Designee will then conduct random chart audits, after 6 months, to ensure compliance is met. |