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 August 6-8, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Kensington Hospital Outpatient Treatment Program 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.
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Plan of Correction
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715.6(a)(2) 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.
(2) When a narcotic treatment program is unable to hire a medical director who meets the qualifications in paragraph (1), the narcotic treatment program may hire an interim medical director. The narcotic treatment program shall develop and submit to the Department for approval a training plan for the interim medical director, addressing the measures to be taken for the interim medical director to achieve minimal competencies and proficiencies until the interim medical director meets qualifications identified in paragraph (1)(i), (ii) or (iii). The interim medical director shall meet the qualifications within 36 months of being hired.
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Observations
Based on a review of personnel records, the facility failed to document the development of a training plan with the interim medical director.
The findings include:
The personnel record of the medical director was reviewed on August 6, 2012. The medical director was hired on September 7, 2011. The facility did not document a year of experience by the medical director in the treatment of narcotic addiction with a narcotic drug. An interview with the medical director confirmed the lack of experience. The medical director was not identified as an interim medical director and did not have a training plan that was developed and submitted to the Department for approval. The facility failed to provide documentation of the required training plan for the interim medical director.
The findings were reviewed with the Project Director, Facility Director and narcotic treatment physician. The findings were not disputed.
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Plan of Correction
A training program has been developed by our CEO and Medical Director to assist in familiarizing our Addictions Medical Director with developing his expertise in overseeing the daily medical issues that surface in our facility. This training program has been established since our Medical Director joined our staff in September, 2011 and will be forwarded to the State. |
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 a review of patient records, the facility 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 4 of 5 records.
The findings include:
Twenty-two patient records were reviewed August 6-8, 2012. Five patient records were reviewed for physician documentation of the basis for determining an individual's physiological dependence upon a narcotic. Four records did not have documentation specifically by the narcotic treatment physician of a face-to-face determination for determining an individual's physiological dependence upon a narcotic, # 13, 20, 21 and 22.
Patient # 13 was admitted February 16, 2012, as a transfer from another narcotic treatment program. There was no documentation verifying that the narcotic treatment physician met with the patient prior to the patient's first dose at this facility. The record indicated the physician approved a dose of 246 mg and this was changed by the dispensing nurse to 245 mg. The physical exam was completed on March 1, 2012.
Patient # 20 was medicated on May 25, 2012, with an admission date of June 1, 2012, as a transfer from another narcotic treatment program. There was no documentation verifying that the narcotic treatment physician met with the patient prior to the patient's first dose at this facility. The physical exam was completed on June 2, 1012.
Patient # 21 was admitted February 9, 2012, as a transfer from another narcotic treatment program. There was no documentation verifying that the narcotic treatment physician met with the patient prior to the patient's first dose at this facility. The physical exam was completed on February 16, 2012.
Patient # 22 was admitted March 23, 2012. The physical exam and the documentation of a face-to-face determination of a 1 year history of addiction was dated March 23, 2012. Documentation of current physiological dependence upon a narcotic drug was not within the patient record at the time of the review.
The findings were reviewed with the Project Director, Facility Director and narcotic treatment physician. The findings were not disputed.
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Plan of Correction
Subsequent to a staff meeting and training held on 9-4-12, the Medical Director of Addictions Services will be responsible for observing and evaluating each patient to confirm their need for medication assisted treatment from a narcotic by using the assessment tools in place, and to confirm that they are in a level of withdrawal in need of our medical services. The Medical Director will also document this on the patient's medical record. The Records Manager will conduct monthly chart reviews to assure continued compliance. |
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 narcotic treatment facility for the patient's treatment history in two of two patient records reviewed.
The findings include:
Twenty-two patient records were reviewed August 6-8, 2012. The review of patient records revealed that two patients possessed prior narcotic treatment experiences that required the facility to contact the prior narcotic treatment program for treatment histories. Patient records # 7 and 22 both contained documentation of previous narcotic treatment involvement but neither record provided documentation of any efforts to obtain prior treatment histories.
Patient # 7 was admitted on March 15, 2012, as a transfer from another narcotic treatment program. Upon review of the record, the patient had multiple previous narcotic treatment experiences. The facility failed to document any efforts to obtain the patient's prior treatment history from a previously attended narcotic treatment facility.
Patient # 22 was admitted on March 23, 2012. The facility failed to document any efforts to obtain the patient's prior treatment history from the previously attended narcotic treatment facility.
The findings were reviewed with the Project Director and the Facility Director. The findings were not disputed.
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Plan of Correction
In the event that a new admission or a transferred client is admitted to our MAT program, the client will sign a consent to release confidential information from their prior treatment experiences to help in verifying the client's need to be engaged in MMTP level of care. This was put into place in a staff meeting facilitated on 9/4/2012, and the record will be monitored by the Director of Addiction Services and the Records Manager whenever a new client is admitted to our MMTP. |
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 obtain an informed and voluntary consent from the patient prior to the disclosure of information in eleven of fifteen patient records.
The findings include:
Twenty-two patient records were reviewed August 6-8, 2012. Fifteen patient records were reviewed for the requirement to include an informed and voluntary consent from the patient prior to the disclosure of information. Eleven of the fifteen patient records, #7, 13, 14, 15, 16, 17, 18, 19, 20, 21 and 22 did not include completed consents prior to the disclosure of information.
Patient # 7 was admitted on March 15, 2012, as a transfer from another narcotic treatment program. This record did not include a release of information for the emergency contact.
Patient # 13 was admitted on February 16, 2012, as a transfer from another narcotic treatment program. This record contained a signed consent to release information to the patient's previous narcotic treatment facility to include only the nature of the project. Information disclosed on February 16, 2012, to the previous narcotic treatment facility, included the patient's admission date and medication dose level. This patient record also contained a signed consent to release information to the patient's funding agency dated January 23, 2012, that included an expiration date of 30 days after the patient's signature. Since the funding agencies require ongoing progress reports for continuing care approval, any information reported to the funding agency after the 30 days of the patient's dated signature was done so without the patient's informed consent. Additionally, a review of the patient's funding status was documented on February 16, 2012, with no signed consent to release information to this funding source in the record.
Patient # 14 was admitted on January 25, 1999. The record included a signed consent to release information to a transportation service dated January 10, 2012, that did not include the specific information to be disclosed. The specific information section on the release of information form was blank.
Patient # 15 was admitted on May 29, 2002. The record failed to document any current signed consents to release information. Since funding agencies require ongoing progress reports for continuing care approval, any information reported to a funding agency was done so without the patient's informed consent.
Patient # 16 was admitted on March 25, 2011. The record failed to document any current signed consents to release information. Since funding agencies require ongoing progress reports for continuing care approval, any information reported to a funding agency was done so without the patient's informed consent.
Patient # 17 was admitted on March 23, 2009. The record failed to document any current signed consents to release information. Since funding agencies require ongoing progress reports for continuing care approval, any information reported to a funding agency was done so without the patient's informed consent.
Patient # 18 was admitted on September 17, 2001. The record failed to document any current signed consents to release information. Since funding agencies require ongoing progress reports for continuing care approval, any information reported to a funding agency was done so without the patient's informed consent.
Patient # 19 was admitted on December 5, 2003. The record contained a signed consent to release information to the patient's funding agency dated January 4, 2012, that included an expiration date of 30 days after the patient's signature. Since the funding agencies require ongoing progress reports for continuing care approval, any information reported to the funding agency after the 30 days of the patient's dated signature was done so without the patient's informed consent.
Patient # 20 was admitted on June 1, 2012. The record contained a signed consent to release information to the patient's funding agency dated June 1, 2012, that included an expiration date of 30 days after the patient's signature. Since the funding agencies require ongoing progress reports for continuing care approval, any information reported to the funding agency after the 30 days of the patient's dated signature was done so without the patient's informed consent. Additionally, a review of the patient's funding status was documented on May 21, 2012, with no signed consent to release information to this funding source in the record.
Patient # 21 was admitted on February 9, 2012. The record contained a signed consent to release information to the patient's funding agency dated February 13, 2012, that included an expiration date of 30 days after the patient's signature. Since the funding agencies require ongoing progress reports for continuing care approval, any information reported to the funding agency after the 30 days of the patient's dated signature was done so without the patient's informed consent. Additionally, a review of the patient's funding status was documented on January 23, 2012, with no signed consent to release information to this funding source in the record.
Patient # 22 was admitted on March 23, 2012. The record contained a signed consent to release information to the patient's funding agency dated March 21, 2012, that included an expiration date of 30 days after the patient's signature. Since the funding agencies require ongoing progress reports for continuing care approval, any information reported to the funding agency after the 30 days of the patient's dated signature was done so without the patient's informed consent. Additionally, a review of the patient's funding status was documented on March 23, 2012, with no signed consent to release information to this funding source in the record.
The findings were reviewed with the Project Director and the Facility Director. The findings were not disputed.
This is a repeat citation from the October 18-20, 2011, on-site inspection for approval.
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Plan of Correction
All records have been audited and
updated by Director of Addictions Services and the Records Manager. Updated, signed releases with the correct time frame for the consent were placed in the client chart. The Records Manager will be responsible to audit all charts on a quarterly basis for compliance with consents and releases. No blank consents or releases are on any client records.
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715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on observation of the dispensing of medication, the review of patient information, and review of administrative documentation, the facility failed to demonstrate the patient's photograph was updated every three years.
The findings include:
The review of the dosing area was conducted on August 7, 2012, at approximately 9:15 AM. During the process of dosing, the patient has a photo identification card created by the narcotic treatment facility that is presented prior to receiving the narcotic agent. The photo identification card was reviewed for an expiration date. There was no date of when the photo was taken or an expiration date. The dispensing nurse was interviewed about the process of updating the patient's photograph during this review. She confirmed there was no expiration date on the card.
The findings were reviewed with the Project Director and the Facility Director. The staff confirmed no expiration date is on the cards.
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Plan of Correction
In order for accurate documentation to occur on a daily basis, the client identification cards must be updated with a current photo, and an expiration date on the card so that the photo does not become outdated. This process was completed by 08/31/2012, with updated photos and expiration dates placed on the front of the identification card. The records personel will ensure that the cards are documented at admission and updated every three (3) years. |
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, the narcotic treatment physician failed to document the dosage level review at least twice a year, with each review occurring at least two months apart, to determine the patient's therapeutic dosage in eight of eleven records.
The findings include:
Twenty-two patient records were reviewed August 6-8, 2012. Eleven patient records were reviewed for documentation of the narcotic treatment physician's review of the patient's therapeutic dosage level. Eight records failed to include documentation that the narcotic treatment physician reviewed the patient's dosage level at least twice a year, specifically patient records # 9, 10, 11, 12, 14, 15, 18 and 19.
Patient # 9 was admitted on December 28, 2004. The record contained no evidence the narcotic treatment physician conducted a dosage review for August 2011 to August 2012.
Patient # 10 was admitted on November 26, 2002. The record contained no evidence the narcotic treatment physician conducted a dosage review for August 2011 to August 2012.
Patient # 11 was admitted on August 17, 2010. The record contained no evidence the narcotic treatment physician conducted a dosage review for August 2011 to August 2012.
Patient # 12 was admitted on December 17, 2007. The record revealed the narcotic treatment physician conducted a dosage review on December 9, 2011. This was the only dose review documented in the record for August 2011 to August 2012.
Patient # 14 was admitted on January 25, 1999. The record revealed the narcotic treatment physician conducted a dosage review on January 12, 2012. This was the only dose review documented in the record for August 2011 to August 2012.
Patient # 15 was admitted on May 29, 2002. The record revealed the narcotic treatment physician conducted an annual physical in August 2011. This was the only dose review documented in the record for August 2011 to August 2012.
Patient # 18 was admitted on September 17, 2001. The record revealed the narcotic treatment physician conducted a dosage review on October 31, 2011. This was the only dose review documented in the record for August 2011 to August 2012.
Patient # 19 was admitted on December 5, 2003. The record revealed the narcotic treatment physician conducted an annual physical on January 5, 2012. This was the only dose review documented in the record for August 2011 to August 2012.
The findings were reviewed with the Project Director, Facility Director and narcotic treatment physician. The findings were not disputed.
This is a repeat citation from the October 18-20, 2011, on-site inspection for approval.
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Plan of Correction
A data base has been developed and the dates for annual medical assessment will correspond with the other two dates on a three time annual timeframe so that medication checks can be facilitated as required in the regulations for MMTP. The Director of Addiction Services will work with the Medical Director and the administrative assistant in checking on the annual date for assessment and set up appointments every four months for medication checks. This was set up during the staff meeting and training facilitated by the Director of Addiction Services and the Medical Director on 9/4/2012 |
715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
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Observations
Based on the review of patient records, the facility failed to ensure the narcotic treatment physician documented in the patient record the rationale for granting take home medication in two of two patient records.
The findings include:
Twenty-two patient records were reviewed August 6-8, 2012. Two patient records were reviewed for take home medication documentation that included the narcotic treatment physician's rationale for permitting take home medication. Patient records # 13 and 18 did not have the physician's rationale for granting the take home medication..
Patient # 13 was admitted on February 16, 2012, as a transfer from another narcotic treatment program. The narcotic physician approved a take home bottle on May 14, 2012. There was no documentation of the physician's rationale for granting the take home medication.
Patient # 18 was admitted on September 17, 2001. The record contained a request for exception take home bottles signed on August 1, 2012, by the narcotic treatment physician. The patient was attending the program twice per week. There was no documentation of the physician's rationale for granting the take home medication.
The findings were reviewed with the Project Director, Facility Director and narcotic treatment physician. The findings were not disputed.
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Plan of Correction
A weekly treatment team meeting will be held after the MMTP clinical staff meeting to discuss any client requests for such matters as client take home meds. The doctor and clinical director will meet with primary counselor to review and act on any take home privileges (THB) for a client. The program Medical Director will discuss the factors presented and will document the rationale used to grant any client THB. This action was discussed and finalized at a staff treatment team meeting on 9-4-12.
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715.16(f) LICENSURE Take-home priveleges
(f) An exception granted under subsection (d) shall continue only for as long as the temporary disability or exceptional circumstance exists. When a patient is permanently disabled, that case shall be reviewed at least annually to determine whether the need for the exception still exists.
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Observations
Based on the review of patient records and a review of administrative documentation, the facility failed to review annually to determine whether the need for the exception for 5 and 6-day take-home still existed.
The findings include:
Twenty-two patient records were reviewed August 6-8, 2012, The Methadone Monitoring Questionnaire documented that three patients at the facility had 5 and 6-day take home privileges due to permanent physical disability. The three records were reviewed for annual documentation that the need for the take home privilege still existed.
Patient # 14 was admitted on January 25, 1999. The facility identified this patient as receiving 6-day take-home bottles due to permanent physical disability per the Methadone Monitoring Questionnaire. The record had no documentation of a review of status since February 9, 2010.
Patient # 15 was admitted on May 29, 2002. The facility identified this patient as receiving 6-day take-home bottles due to permanent physical disability per the Methadone Monitoring Questionnaire. The record had no documentation of a review for August 2011 to August 2012.
Patient # 18 was admitted on September 17, 2001. The facility identified this patient as receiving 5-day take-home bottles due to permanent physical disability per the Methadone Monitoring Questionnaire. The record documented a positivie illicit substance urine screen in July 2012. The record had no documentation of a review of the use of illicit substances on the 5-day take-home privileges.
The findings were reviewed with the Project Director and the Facility Director. The findings were not disputed.
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Plan of Correction
The Medical Director, with a signed consent, will consult with the client's physician regarding need for medical exceptions for THB. The final determination and documentation will be completed by the Medical Director. Included in this documentation will be the medical rationale for approval for THB. Monthly record audits will be done by the Records Manager to assure continued compliance. |
715.17(c)(3)(i-v) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(3) Inspection of storage areas. A narcotic treatment program shall inspect all drug storage areas and the dispensing station at least quarterly to ensure that the areas are maintained in compliance with Federal, State and local laws and regulations. A narcotic treatment program shall develop and implement written policies and procedures regarding who performs the inspections, how often, and in what manner the inspections are to be documented. The policies and procedures shall include the following:
(i) Disinfectants and drugs for external use shall be stored separately from oral and injectable drugs.
(ii) Drugs requiring special conditions for storage to insure stability shall be properly stored.
(iii) Outdated and contaminated drugs shall be removed and destroyed according to Federal and State regulations.
(iv) Administration of controlled substances shall be documented.
(v) Controlled substances and other abusable drugs shall be stored in accordance with Federal and State regulations.
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Observations
Based on the review of administrative documentation, the facility failed to follow their policy respective to completing inspections of the drug storage areas and the dispensing station.
The findings include;
The policy and procedure manual was reviewed August 6, 2012. The policy related to the frequency of inspecting the drug storage and dispensing station stated the inspections were to be conducted on a monthly basis by the hospital pharmacist or designee. The documentation pertaining to the monthly inspections was requested on August 7, 2012. The dispensing nurse reported there was no documentation of the inspections kept in the dispensing station or within the facility.
The findings were reviewed with the Project Director and the Facility Director. The findings were not disputed.
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Plan of Correction
Monthly inspections of the drug storage and dispensing station are conducted by the Pharmacist and documentation is kept on file in the Pharmacy. A copy of these inspection reports will also be maintained in the Outpatient Treatment Program. Monthly reviews of these inspections reports will be done in the Outpatient Treatment Program by the Pharamcist as part of the on-going Performance Improvement Program. |
715.18(a)(4) LICENSURE Rehabilitative services
a) A narcotic treatment program shall provide, either onsite or through referral agreements, a full range of rehabilitative services. Rehabilitative services shall include:
(4) Behavioral health services
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Observations
Based on the review of administrative documentation, the facility failed to demonstrate that rehabilitative services could be made available to patients as needed.
The findings include;
The policy and procedure manual was reviewed August 6, 2012. The documentation pertaining to the rehabilitative services was requested on August 6, 2012. The facility lacked documentation of on-site provisions or referral agreements for employment services, adult educational services, behavioral health services and legal services that could be made available to patients as needed.
The findings were reviewed with the Project Director and the Facility Director. The findings were not disputed.
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Plan of Correction
Individual contracts will be obtained for the following services: housing, educationl, job preparation. legal and family services. Contracts will be in placed by 11/30/12. The Records Manager will also review the contracts file every six (6) months to assure current contracts. |
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.
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Observations
Based on a review of patient records, 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 six records.
The findings include:
Twenty-two patient records were reviewed August 6-8, 2012. Six patient records were reviewed for psychotherapy hours during the first year of treatment. Two patient records, # 11 and 16, failed to have the average of 2.5 hours of psychotherapy per month during their first 2 years of treatment.
Patient # 11 was admitted on August 17, 2010. The psychotherapy hours are documented for every other month with no reason cited for the decrease in frequency. The record also documents urine screens positive for illicit substances.
Patient # 16 was admitted on March 25, 2011. The average therapy hours were reviewed for the months of May, June and July of 2012. The patient averaged 2.17 hours of psychotherapy for the three months reviewed.
The findings were reviewed with the Project Director and the Facility Director. The findings were not disputed.
This is a repeat citation from the October 18-20, 2011, on-site inspection for approval.
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Plan of Correction
Each counselor is responsible for submitting weekly encounter reports to the Director of Addiction Services to assure compliance with minimun psychotherapy treatment contact hours.
The Director will also monitor encounter reports along with UDS's to update client progress and treatment minimums. This will assure continued compliance.
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715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide each patient 1 hour of psychotherapy every other month after the 4 years of treatment in two of eight records.
The findings include:
Twenty-two patient records were reviewed August 6-8, 2012. Eight patient records were reviewed for psychotherapy hours after 4 years of treatment. Two patient records, # 10 and 18, failed to have 1 hour of psychotherapy every other month.
Patient # 10 was admitted on November 26, 2002. The psychotherapy services were documented for 1 hour on May 7, 2012. There was no documentation of psychotherapy services in July 2012.
Patient # 18 was admitted on September 17, 2001. The record has no documentation of psychotherapy services since March of 2012.
The findings were reviewed with the Project Director and the Facility Director. The findings were not disputed.
This is a repeat citation from the October 18-20, 2011, on-site inspection for approval.
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Plan of Correction
Each counselor is responsible for submitting weekly encounter reports to the Director of Addiction Services to assure compliance with minimun psychotherapy treatment contact hours. The Director will also monitor encounter reports along with UDS's to update client progress and treatment minimums. This will assure continued compliance. |
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 the review of patient records, the facility failed to restrict the reasons for involuntary termination to those reasons allowed by regulation in three of three patient records.
The findings include:
Twenty-two patient records were reviewed August 6-8, 2012. Three patient records were reviewed for involuntary, or therapeutic, discharge. All patient records contained documentation of the patient being discharged for reasons other than those listed by regulation.
Patient # 1 was admitted on September 21, 2011, and discharged on April 26, 2012. The involuntary discharge letter dated April 16, 2012, indicated the patient was being discharged due to multiple violations of program rules and failure to participate in the treatment plan. The record indicated the patient hid a urine which fell out in front of security staff. The reasons listed are not included in the regulation.
Patient # 2 was admitted on May 10, 2012, and discharged on July 30, 2012. The involuntary discharge letter dated July 25, 2012, indicated the patient was being discharged due to non compliance with program rules. The reason listed was not included in the regulation.
Patient # 3 was admitted on January 30, 2012, and discharged on June 20, 2012. The involuntary discharge letter dated June 12, 2012, indicated the patient was being discharged due to failure to participate in the treatment program and excessive absences. The reasons listed are not included in the regulation.
The findings were reviewed with the Project Director and the Facility Director. The findings were not disputed.
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Plan of Correction
A second staff meeting was held on 9-20-12 to review and revise the standards that dictate an administrarive discharge from our MMTP. The rules regarding threats and violence and selling or purchasing illicit drugs on site will be grounds for administrative discharge. These rules were printed and distributed to the clients in our MMTP. The final determination for administrative discharge and detox is decided by the Medical Director. The Records Manager will conduct monthly chart reviews to assure on-going compliance. |
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 a review of patient records, the facility failed to complete the annual physical with a re-evaluation by the narcotic treatment physician in four of eleven patient records reviewed.
The findings include:
Twenty-two patient records were reviewed August 6-8, 2012. Eleven patient records were reviewed for the annual physical with a re-evaluation by the physician. Four patient records, # 9, 11, 16, and 17, failed to have documentation of the annual physical with a re-evaluation.
Patient # 9 was admitted on December 29, 2004. The annual physical exam was last documented on December 1, 2010, with no further documentation. An annual physical exam was due by December 29, 2011.
Patient # 11 was admitted on August 17, 2010. The admission physical exam was the last documented exam in the record. An annual physical exam was due by August 17, 2011.
Patient # 16 was admitted on March 25, 2011. The annual physical exam dated on June 21, 2012, was due by March 25, 2012. There was no documentation of re-evaluation by the narcotic treatment physician.
Patient # 17 was admitted on March 23, 2009. The annual physical exam was last documented on April 5, 2011, with no further documentation. An annual physical exam was due by March 23, 2012.
The findings were reviewed with the Project Director, the Facility Director, and the narcotic treatment physician. The findings were not disputed.
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Plan of Correction
Each client will have an annual physical exam done by the physician nce the patient completes their annual date of admission to MMTP. The Records Manager will monitor the data base to alert the physician the annual physical exam is due. The Records Manager will conduct monthly chart reviews to assure continued compliance. |
715.23(b)(14) LICENSURE Patient records
(b) Each patient file shall include the following information:
(14) Case consultation notes regarding the patient.
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Observations
Based on the review of patient records, the facility failed to document case consultations in seven of fifteen records.
The findings include:
Twenty-two patient records were reviewed August 6-8, 2012. Fifteen patient records were reviewed for case consultations. Seven patient records failed to document case consultations, # 10, 15, 16, 17, 18, 19 and 21.
Patient # 10 was admitted on November 26, 2002. An annual case consultation was due by November 26, 2011. No documentation was found in the record at the time of the review.
Patient # 15 was admitted on May 29, 2002. An annual case consultation was documented for June 16, 2011. An annual case consultation was due by May 29, 2012. No documentation was found in the record at the time of the review.
Patient # 16 was admitted on March 25, 2011. The annual case consultation dated May 17, 2012, was due by March 25, 2012.
Patient # 17 was admitted on March 23, 2009. An annual case consultation was documented for April, 2010. An annual case consultation was due by March 23, 2012. No documentation was found in the record at the time of the review.
Patient # 18 was admitted on September 17, 2001. An annual case consultation was documented for January 26, 2011. An annual case consultation was due by September 17, 2011. No documentation was found in the record at the time of the review.
Patient # 19 was admitted on December 5, 2003. An annual case consultation was due by December 5, 2011. No documentation was found in the record at the time of the review.
Patient # 21 was admitted on February 9, 2012. A quarterly case consult was completed on May 9, 2012. The facility failed to document the staff involved in the consult.
The findings were reviewed with the Project Director and the Facility Director. The findings were not disputed.
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Plan of Correction
It was decided during a staff training and meeting on 9-20-12 that all client charts during the first year in treatment will have a minimum of four case consultations, one completed every three months to review the progress that the client is experiencing in their first year in MMTP. There should also be Case Consultations completed in a timely fashion when a situation results in the client needing to present in a staff setting. The client charts will be closely monitored, and due dates will be given to the primary therapist providing services to clients working in their first year in MMTP. This compliance with this quarterly review will be monitored by the Director of Addictions Services. |
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 the review of patient records, the facility failed to ensure the psychosocial evaluations were a clinical assessment of the historical data collected in five of five patient records.
The findings include:
Twenty-two patient records were reviewed August 6-8, 2012. Five patient records were reviewed for psychosocial evaluations, # 7, 13, 20, 21 and 22.
Patient # 7 was admitted on March 15, 2012. A psychosocial evaluation was found in the record without a date of documentation. It is not possible to ascertain the compliance of the documentation within 30 days of admission.
Patient # 13 was admitted on February 16, 2012. The psychosocial evaluation was dated January 24, 2012. It consisted of a composite picture of the patient with no clinical assessment documented.
Patient # 20 was admitted on June 1, 2012. The psychosocial evaluation was dated June 1, 2012. It consisted of a composite picture of the patient with no clinical assessment documented.
Patient # 21 was admitted on February 9, 2012. The psychosocial evaluation was dated February 13, 2012. It consisted of a composite picture of the patient with no clinical assessment documented.
Patient # 22 was admitted on March 23, 2012. The psychosocial evaluation was dated March 23, 2012. It consisted of a composite picture of the patient with no clinical assessment documented.
The findings were reviewed with the Project Director and Facility Director. The findings were not disputed.
This is a repeat citation from the October 18-20, 2011, on-site inspection for approval.
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Plan of Correction
The use of the Bio-Psycho-Social history will be changed to better assess the client rather than repeat the historical facts that the client presented during the BPS fact finding task. A new question and answer format has been developed and put in place by the Director of Addictions Services to better utilize the personal reflections that clients give during this session. The new format will use probing questions such as why, how long, and did you ever, rather than the usual what and when. The assessments will be reviewed by the Director of Addictions Services to insure that the assessment is effective. This new assessment tool was put into effect 10-1-12. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on the review of patient records, the facility failed to document a discharge summary including all of the content in four of six patient records.
The findings include:
Twenty-two patient records were reviewed August 6-8, 2012. Six patient records were reviewed for discharge summaries. Four of the records failed to provide complete discharge summaries, # 1, 3, 5 and 6.
Patient # 1 was admitted on September 21, 2011, and discharged on April 26, 2012. A discharge summary was not located in the record at the time of the review.
Patient # 3 was admitted on January 30, 2012, and discharged on June 20, 2012. The discharge summary did not address the type of discharge.
Patient # 5 was admitted on August 24, 2000, and discharged on October 18, 2011, due to the patient being deceased. A discharge summary was not located in the record at the time of the review.
Patient # 6 was admitted on September 19, 2007, and discharged on June 22, 2012. The discharge summary did not address the type of discharge.
The findings were reviewed with the Project Director and Facility Director. The findings were not disputed.
This is a repeat citation from the October 18-20, 2011, on-site inspection for approval.
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Plan of Correction
A staff meeting and training were held on 9-4-12 at which time the discharge summary was revised and reviewed by the clinical staff of the MMTP. The form was put into action subsequent to this meeting, and all of the clinicians were familiarized swith what was expected from them in documenting a discharge summary. The Director of Addiction Services will be responsible for monitoring the proper use of the discharge summary as well the record manager to make sure that a discharge summary is included in every dicshaged client's chart. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on the review of patient records, the facility failed to document an attempt or completion of patient follow up contact in three of four patient records.
The findings include:
Twenty-two patient records were reviewed August 6-8, 2012. Four patient records were reviewed for documentation of an attempt or completion of a follow up contact. Three of the records failed to provide the documentation, # 1, 3 and 6.
Patient # 1 was admitted on September 21, 2011, and discharged on April 26, 2012. There was no evidence of an attempt to contact the patient for follow up at the time of the review.
Patient # 3 was admitted on January 30, 2012, and discharged on June 20, 2012. There was no evidence of an attempt to contact the patient for follow up at the time of the review.
Patient # 6 was admitted on September 19, 2007, and discharged on June 22, 2012. There was no evidence of an attempt to contact the patient for follow up at the time of the review.
The findings were reviewed with the Project Director and Facility Director. The findings were not disputed.
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Plan of Correction
Subsequent to client discharge, clinical staff will contact ex-client within 30 days by mail regarding follow up report. Another contact will be attempted after 90 days. A copy of both letters will be placed in chart. The Records Managers will conduct monthly chart reviews to assure continued compliance. |
715.23(b)(25) LICENSURE Patient records
(b) Each patient file shall include the following information:
(25) Documentation of patient grievances.
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Observations
Based on the review of patient records and administrative documentation, the facility failed to document patient grievances in the patient record, # 8.
The findings include:
Twenty-two patient records were reviewed August 6-8, 2012. One patient record was reviewed for documentation of a patient grievance. Patient # 8 was admitted on December 8, 2005. This patient filed a grievance regarding a loss of a take home bottle. The grievance was documented in the grievance binder. The patient record had no documentation of the grievance filed or resolved.
The findings were reviewed with the Project Director and Facility Director. The findings were not disputed.
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Plan of Correction
When a grievance is filed, it is the responsibility of the Program Director to investigate and respond to the client within 72 hours of receipt of grievance. The grievance will be kept on file in the Director of Addiction Services' office, as well as, documented on the patient's medical record. The client grievance log will be reviewed weekly by the Director of Addiction Services to assure continued compliance. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on the review of patient records, the facility failed to ensure the annual evaluations were documented in ten of ten patient records.
The findings include:
Twenty-two patient records were reviewed August 6-8, 2012. Ten patient records were reviewed for documentation of an annual evaluation of each patient's status on or about the patient's anniversary date, # 8, 9, 10, 11, 14, 15, 16, 17, 18 and 19.
Patient # 8 was admitted on December 8, 2005. An annual evaluation was due on or about December 8, 2011. An annual evaluation was not located in the record at the time of the review.
Patient # 9 was admitted on December 28, 2004. An annual evaluation was due on or about December 28, 2011. An annual evaluation was last documented on December 24, 2010.
Patient # 10 was admitted on November 26, 2002. An annual evaluation was due on or about November 26, 2011. An annual evaluation was last documented on November 26, 2009.
Patient # 11 was admitted on August 17, 2010. An annual evaluation was due on or about August 17, 2011. An annual evaluation was not located in the record at the time of the review.
Patient # 14 was admitted on January 25, 1999. An annual evaluation was due on or about January 25, 2012. An annual evaluation was documented on February 29, 2012, a month late.
Patient # 15 was admitted on May 29, 2002. An annual evaluation was due on or about May 29, 2012. An annual evaluation was last documented on October 10, 2009.
Patient # 16 was admitted on March 25, 2011. An annual evaluation was due on or about March 25, 2012. An annual evaluation was last documented on June 26, 2012, several months late.
Patient # 17 was admitted on March 23, 2009. An annual evaluation was due on or about March 23, 2012. An annual evaluation was last documented in April 2010.
Patient # 18 was admitted on September 17, 2001. An annual evaluation was due on or about September 17, 2011. An annual evaluation was last documented on January 26, 2011.
Patient # 19 was admitted on December 5, 2003. An annual evaluation was due on or about December 5, 2011. An annual evaluation was last documented on February 21, 2011.
The findings were reviewed with the Project Director and the Facility Director. The findings were not disputed.
This is a repeat citation from the October 18-20, 2011, on-site inspection for approval.
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Plan of Correction
The plan of corrective action has been designed to prevent client records from lacking annual evaluations subsequent to the client anniversary date. All appointments relating to annual evaluations shall not be re-scheduled, or cancelled. It is the responsibility of the Addictions Services Director to make sure that when the data base signals a need to schedule an annual evaluation it will be completed by the clinician and documented on the medical record as stated in the regulations by both the medical and clinical staff. The Records Manager will conduct monthly chart reviews to assure continued compliance.
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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 the review of patient records, the facility failed to document the progress or lack of progress in achieving the goal statements from the prior treatment plan in five of fifteen patient records.
The findings include:
Twenty-two patient records were reviewed August 6-8, 2012. Fifteen patient records were reviewed for treatment plan update documentation. Five patient records, # 12, 15, 17, 18 and 19, failed to provide treatment plan updates that showed progress or lack of progress.
Patient # 12 was admitted on December 17, 2007. Treatment plan updates were documented for February 7, 2012, April 6, 2012, and June 7, 2012. The documentation did not identify progress as the goals, interventions, and evaluation were identical on each update.
Patient # 15 was admitted on May 29, 2002. Treatment plan updates were documented for February 13, 2012, April 23, 2012, and June 21, 2012. The documentation did not identify progress as the goals, interventions, and evaluation were identical on each update.
Patient # 17 was admitted on March 23, 2009. Treatment plan updates were documented for February 29, 2012, and June 29, 2012. A treatment plan update was not documented for April 2012. The documentation did not identify progress as the goals and interventions were identical on each update. The June 29, 2012, treatment plan update had no content in the area for progress documentation.
Patient # 18 was admitted on September 17, 2001. Treatment plan updates were documented for March 9, 2012, May 9, 2012, and July 9, 2012. The documentation did not identify progress as the evaluations were identical on each update.
Patient # 19 was admitted on December 5, 2003. Treatment plan updates were documented for February 9, 2012, April 9, 2012, and June 8, 2012. The documentation did not identify progress as the goals, interventions, and evaluation were identical on each update.
The findings were reviewed with the Project Director and the Facility Director. The findings were not disputed.
This is a repeat citation from the October 18-20, 2011, on-site inspection for approval.
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Plan of Correction
The therapists have been given ample space and opportunity to make progress statements covering each client in each treatment plan update. The staff was famililarized with this statement and what should be included in the documentation of the client progress in a staff meeting and training held on 9-4-12, and a subsequent one on 9-20-12. It has now become the responsibility of the Director to make sure that progress statements are included on the front page of the treatment plan update. |
715.28(b)(1-4) LICENSURE Unusual incidents
(b) These policies and procedures shall include the following:
(1) Documentation of the unusual incident.
(2) Prompt review and investigation.
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
(4) Ongoing monitoring of the corrective action plan.
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Observations
Based on the review of administrative documentation, the facility failed to document all areas required for incident reporting in five of eight reports.
The findings include:
Eight incident reports were reviewed on August 7, 2012. All required complete documentation in the report. Five incident reports failed to include documentation of the review and investigation as well as a timely, appropriate and ongoing monitoring of the corrective action plan.
The findings were reviewed with the Project Director and Facility Director. The findings were not disputed.
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Plan of Correction
A training and staff meeting were facilitated on 9-4-12. At that time we reviewed old incident reports for various reasons and the clinical staff were given situations to, first, determine whether an incident report was necessary. Second, it was also at that time that all of the staff were given the task of reporting an incident and filing an incident report with the Director and with administraion. Then the staff was asked to review the incident, how the same incident could be prevented from surfacing again, and what measures could be taken to form a corrective plan of action for prevention of the same thing happening. The Director of Addictions Services was also designated to complete internal check to see what happened, any injuries, and to see who was responsible and how the same incident could be prevented from happening again. |
715.29(5) 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.
(5) If the exception relates to a specific patient, the narcotic treatment program shall maintain documentation of the exception in the patient 's record.
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Observations
Based on the review of patient records and administrative documentation, the facility failed to request an exception to provide oral drug screens in patient record, # 18.
The findings include:
Twenty-two patient records were reviewed August 6-8, 2012. One patient record was reviewed for documentation of an exception. Patient # 18 was admitted on September 17, 2001. This patient is provided an oral drug test. An exception is not filed with the Department to provide this alternative drug test.
The findings were reviewed with the Project Director and Facility Director. The findings were not disputed.
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Plan of Correction
All drug screens will be done by Atlantic Diagnostic Laboratory with a confirmed written printed report prior to a patient being admitted to the Outpatient Treatment Program. The Records Manager will conduct monthly chart reviews to assure continued compliance. |