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 March 3-6, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Consortium 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 April 3, 2008.
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Plan of Correction
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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 a review of 17 patient records, the facility failed to ensure the completion of random urine drug screens at least monthly in one of six patient records, specifically # 17. Patient #17 was admitted February 14, 2008, but had an admission urine drug screen January 30, 2008 and again was screened in March 2008.
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Plan of Correction
715.14(a) Urine testing
A monthly Toxicology screening was missing for a chart
POC: The computerized dispensing system provides a schedule for a monthly toxicology screenings. In addition. The Head Nurse will implement a monthly review to insure all required testing is complete. This review will be documented in a monthly log.
RESPONSIBLE PERSON/MONITORING: OTS Head Nurse
TIME LINE: Effective 4-1-08
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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 a review of 17 patient records, the facility failed to ensure there was documentation of the most recent exception for patient #15 who is experiencing a temporary disability interfering with the patient's ability to attend the mandatory schedule as required. Specifically, the facility had initially requested and received an exception from the Department for patient #15 for four (4) weekly take home medication bottles with onsite dosing Monday, Wednesday and Friday. However, due to deterioration in the patient's pregnancy status, the patient was restricted to bedrest and requested the facility provide six (6) take home medication bottles with patient attending for onsite dosing once weekly. The facility physician failed to document and file an exception in the patient record as required for this 6 day take home schedule.
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Plan of Correction
715.16(d)(1-3) Take-home privileges
The program had an exception for a high risk pregnancy allowing for 4 TH bottles. The Physician increased the TH to 6 TH bottles but failed to document the modification
POC: 1) A staff training on DOH TH regulations will be conducted, 2) The program will expand its Take Home audit process to include the review of exception requests documentation and 3) the Head Nurse will monitor compliance with/ submission to DOH Take Home bottle exceptions
RESPONSIBLE PERSON/ MONITORING: OTS Medical Director, OTS Head Nurse & OTS Division Director
TIME LINE: Effective 5-1-08
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715.23(b)(13) LICENSURE Patient records
(b) Each patient file shall include the following information:
(13) Patient record of services.
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Observations
Based on a review of 17 patient records, the facility failed to ensure the patient's record of services was complete and current in 7 of 10 patient records reviewed, specifically, # 9, 10, 11, 12, 14, 15, and 16. Patient #9 was missing the services provided in February; patients #10, 12, 14, 15 and 16 had progress notes up to the week prior to the inspection, but the services were not completed for January and February 2008; and patient #11 the last entry recorded for services delivered was December 2007.
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Plan of Correction
715.23(b)(13) Patient records Record of Services
The medical record, patient files, lacked consistent Record of Service reports. The reports are currently done manually by medical records staff as clinical documentation is filed
POC: The program will use its billing system to print out, on a monthly schedule, an electronic record of service. The format for the record of service report will meet or exceed all DOH standards
RESPONSIBLE PERSON/ MONITORING: Consortium Director of IT & Compliance will facilitate the report printing format and the Medical Records staff will print the report for each patient by the 20th day of the preceding month. Process will be monitored by OTS Clinical Director & OTS Division Director
TIME LINE: Effective 6-1-08
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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 a review of 17 patient records, the facility failed to ensure that a clinical analysis of the collected historical data was documented in one of two patient records reviewed, specifically patient # 15. In addition, patient #17 was readmitted and the facility failed to develop a new psychosocial evaluation.
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Plan of Correction
715.23(b)(15) Patient records Psychosocial History & Evaluation
The program failed to comply with the development of a new psychosocial history and evaluation for a newly re-admitted person. The two admissions were admitted as exceptions and did not go through the formal intake process.
POC: 1) The program will provide staff training on the admission process and required documentation. and 2) The program will require all admissions and re-admissions to cycle through the formal intake process.
RESPONSIBLE PERSON/ MONITORING: The OTS Clinical Director and OTS Division Director
TIME LINE: Effective 4-1-08
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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 a review of 17 patient records, the facility failed to ensure treatment plan updates were completed according to the facility's policy and procedure that requires updates every 30 days for patients attending IOP level of care. This occurred in two of five patient records reviewed, specifically patients # 11 (last done 1-10-08) and # 16 (last done 10-12-07). In addition, the facility failed to document the patient's progress towards meeting the goals as documented by a general progress statement in patient record # 12.
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Plan of Correction
715.23(d)(2) Patient records Treatment Plans
The program failed to comply with its internal policy requiring Treatment Plans 1x per month for IOP enrolled people.
POC: 1) A staff training will be conducted on treatment planning, content, timing and compliance. 2)Program management has modified the system for collection and monitoring of IOP treatment plans. The new process requires that all IOP treatment plans be submitted on a single date and that the submissions are documented on the management GRID. The management GRID is a shared file for all staff to monitor
RESPONSIBLE PERSON/ MONITORING: The OTS-IOP Clinical Supervisors
TIME LINE: Effective 5-1-08
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