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 February 18-20, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health System 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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715.8(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.
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Observations
Based on a review of the Narcotic Treatment Program Monitoring Questionnaire, the facility failed to comply with the 35:1 full time equivalent caseload.
The findings include:
The Narcotic Treatment Program Monitoring Questionnaire was reviewed on February 18 - 20, 2014. The facility failed to comply with the 35:1 full time equivalent caseload. The Narcotic Treatment Program Monitoring Questionnaire identified three counselors on leave of absence. However, it was later revealed that at least five counselors were on leave of absence.
The Narcotic Treatment Program Monitoring Questionnaire identified 752 outpatient clients, 644 which were receiving Methadone Monitoring.
The Narcotic Treatment Program Monitoring Questionnaire listed a total of three clinical supervisors and twenty-two counselors. Two counselors were not assigned patients on the caseload page, and one counselor was assigned thirty-four patients, but had "LOA" (Leave of Absence) next to the number of patients. The clinical supervisor also reported two additional counselors were on leave of absence for a total of five unassigned caseloads.
Based on a conversation with the clinical supervisor, the clinical supervisors did not have a caseload and had additional assignments which were not directly related to counseling or clinical supervision. The staff interviews confirmed that there were patients not assigned to counselors at the time of the inspection.
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Plan of Correction
On March 7, 2014 two counselors returned from FMLA leave. A new counselor was also hired on March 3 , 2014. The addition of a new counslor and the return of two counselor places Goldman close to being fully staff. Goldman Clinic has one open counselor slot and two staff on intermitten FMLA,currently. To address the facility failure to comply with 35:1 full time equivalent caseload :
1) The Director and/or clinical
coordinator will reassign
participants who do not have a
counselor to staff that are below
the 35:1 ratio
2) If all available counselors are at
the 35:1 ratio. The Director
and/or clinical coordinator will
assign unassigned participants to
clinical supervisors.
3) The Director will make a request for
a temp. counselor to the VP of
Behavioral Health , if need
be .
4) Director of Goldman Clinic and
Clinical coordinator will monitor
staffing ratio monthly to assure
full compliance to this plan of
correction.
5) Director of Goldman Clinic will be
responsible for implementing this
plan of correction.
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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 a review of patient records, the facility failed to contact the previous narcotic treatment facility for the patient's treatment history in one of one patient records reviewed.
The findings include:
Twenty-eight patient records were reviewed February 18-20, 2014. One patient record reviewed required contacting the prior narcotic treatment facility for the previous treatment history the patient reported to have received.
Patient record # 2 contained documentation the patient had received narcotic treatment services previously at another narcotic treatment program. There was no documentation of an attempt to obtain the previous treatment history from the identified previous narcotic treatment program.
This is a repeat citation. The facility was previously cited for non-compliance on June 28, 2013.
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Plan of Correction
To address facility failure to contact and request a participants' previous treatment history , Goldman Clinic will:
1) During intake , clinical
coordination will complete a release
with the participant to request
information from their previous
treatment programs related to their
course of treatment and
history. A copy of the fax'd request
will be placed in the chart. Upon
recieving information,data will be
placed in chart.
2) Clinical Supervisors will instruct
counselors to audit charts for
document of previous treatment
histories. If,there is no previous
treatment information , Counselor
will contact participant to complete
a release to request information
from their previous treatment
programs related to their
course of treatment and
history. A copy of the fax'd request
will be placed in the chart. Upon
receiving information, data will be
placed in chart
3) Clinical supervisors will audit
charts monthly to assess if 100%
compliance to this plan of
correction has been achieved and
maintained.
4) Clinical supervisors will be
responsible for providing in-
services during treatment team
and/or supervision, if this
plan of correction's 100% benchmark
is not met by counseling staff.
5) Patient record# 2 will be reviewed
by counselor . Counselor will
contact participant to complete a
release to request
information from their previous
treatment programs related to their
course of treatment and
history.A copy of the fax'd request
will be placed in the chart. Upon
recieving information,data will be
placed in chart
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715.10(b) LICENSURE Pregnant patients
(b) A narcotic treatment program shall give pregnant patients the opportunity for prenatal care either by the narcotic treatment program or by referral to appropriate health-care providers.
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Observations
Based on the review of patient records, the facility failed to document the provision of prenatal care in two of four patient records.
The findings include:
Twenty eight patient records were reviewed February 18-20, 2014, four were reviewed for the provision of or referral for prenatal care. There was no documentation the patient was receiving prenatal services in patient records # 25 or # 26 at the time of the survey.
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Plan of Correction
To address the facility failure to document the provision prenatal care :
1) A pregnancy test shall be performed
for all prospective female
participant of childbearing age upon
admission to comprehensive
medication assisted treatment
program. Once it has been determined
that the female participant is
pregnant, the participant is put in
blue status pregnant status) on the
Avatar Radplus System. The nursing
staff receiving the pregnancy
positive result will inform the
medical doctor, case manager, and
counselor.
2) A pregnancy test will be performed
annually on females at Goldman
Clinic.The nursing staff receiving
the pregnancy positive results will
inform the medical doctor, case
manager,and counselor.
3) Medical Director,Counselor and
casemanager will inform all female
participants of childbearing age
of the possible risk to herself and
the unborn child due to continued
illicit drug use and the use of, or
withdrawal from, a narcotic drug
administered or dispensed by the
Program while in medication assisted
treatment or detoxification
treatment
4) Pregnant participant shall be
provided the opportunity to receive
prenatal care by the Program
Physician or by referral to
appropriate health care providers.
5) The participant must sign a release
of information form authorizing the
release of confidential information
to the receiving clinic and approval
for follow-up contact, which the
counselor or casemanager will fax.
6) After the delivery, the Case Manager
together with the Counselor will
continue to provide support and
follow-up with participant's
postnatal care.
7) The nature of the prenatal and
postnatal care and support shall be
documented in the participant's
record.
8) Patient records # 25 and # 26 will
review and particitpants
interview to gather infromation
about their prenatal and postnatal
care and support by counselor and
casaemanager.
9) Medical Director , Clinical
supervisiors will monitor counselors
and casemanger ability to follow
Policy :715.10
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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 patient records, the facility failed to complete a random urinalysis at least monthly in seven of twenty-five patient records reviewed.
The findings include:
Twenty-eight patient records were reviewed on February 18-20, 2014. Twenty-five patient records were reviewed for documentation of a random monthly urinalysis. The facility failed to document random monthly urinalysis in seven patient records, patient record # 9, 10, 11, 12, 14, 15, and 20.
At the time of the survey, the facility failed to document a random monthly urinalysis during the month of October 2013 for patient # 9.
At the time of the survey, the facility failed to document a random monthly urinalysis during the month of June 2013 for patient # 10.
At the time of the survey, the facility failed to document a random monthly urinalysis during the month of June 2013 for patient # 11.
At the time of the survey, the facility failed to document a random monthly urinalysis during the month of December 2013 and January 2014 for patient # 12 who was still an active client at the time of review.
At the time of the survey, the facility failed to document a random monthly urinalysis during the month of September 2013 for patient # 14.
At the time of the survey, the facility failed to document a random monthly urinalysis during the month of August 2013 for patient # 15.
At the time of the survey, the facility failed to document a random monthly urinalysis during the month of July 2013, September 2013, December 2013 and January 2014 for patient # 20 who was still an active client at the time of review.
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Plan of Correction
The facility failed to complete a random urinalysis at least monthly:
1) Counselor will review UDS each
month with participant for strenght-
base discussion, if UDS is
not present, contact
clinical supervisor to
assited with obtaining UDS
2) Clinical Supervisors will perform a
in-service on the importance of
monitoring urine results and
evidents of UDS results
documentation in chart
on 4/21/20014.
3) Each Clinical supervisor will review
(24)charts each month for compliance
policy 715.4 urine drug a 100 %
bench.
4) Patient record # 9, 10,11,12. 14,
15, and 20 will be requested from
the lab. and placed in chart.
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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 at least 1 hour every two months of group or individual psychotherapy after four years of treatment in four of twelve patient records reviewed.
The findings include:
Twenty-eight patient records were reviewed on February 18-20, 2014. Twelve patients were required to receive at least 1 hour per month of group or individual psychotherapy. The facility failed to provide at least 1 hour per month of group or individual psychotherapy per month in four out of twelve patient records reviewed, patient record # 11, 12, 21, and 23.
Patient # 11 was admitted 3/6/02 and was still an active patient at the time of review. Patient # 11 was required to receive at least 1 hour of group or individual psychotherapy every 2 months. The facility failed to provide counseling during the month of December 2013 and January 2014.
Patient # 12 was admitted 1988 and was still an active patient at the time of review. Patient # 12 was required to receive at least 1 hour of group or individual psychotherapy every 2 months. The facility failed to provide counseling during the month of October 2013, November 2013, December 2013, and January 2014.
Patient # 21 was admitted 3/20/03 and was still an active patient at the time of review. Patient # 21 was required to receive at least 1 hour of group or individual psychotherapy every 2 months. The facility failed to provide counseling during the month of December 2013 and January 2014.
Patient # 23 was admitted 7/11/01 and was still an active patient at the time of review. Patient # 23 was required to receive at least 1 hour of group or individual psychotherapy every 2 months. The facility failed to provide counseling during the month of December 2013 and January 2014.
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Plan of Correction
The facility failed to provide each patient at least 1 hour every two months of group or individual psychotherapy after four years of treatment.
1) Clinical Supervisors will obtain a
current listing of participants with
4 or more years of treatment to
monitor scheduling by
counselors
2) Counselers will schedule
participants with 4 or more years of
treatment to least 1 hour of
individual psychotherapy .
3) Clincial supervisors will monitor
counselors' quality and quantity of
work related to providing least 1
hour of individual psychotherapy a
month.
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715.22(a) LICENSURE Patient grievance procedures
(a) A narcotic treatment program shall develop and utilize a patient grievance procedure.
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Observations
Based on a review of the grievances filed in 2013, the facility failed to utilize the patient grievance procedure.
The findings include:
On January 19, 2014, the patient grievance procedure and the patient grievances filed during the 2013 year were reviewed. There were no documented responses to grievances filed for three specific grievances filed during 2013.
# 1- the patient filed a grievance because the patient believed a staff person had violated the patient's confidentiality. There was very specific information documented in the grievance, but there was no response to the grievance included.
# 2 - a grievance was filed because a patient was selling his/her food stamps and transportation pass to a specifically identified security guard. A response was not included in the patient record. The facility director reported to this writer that it was directed to the security firm. There was no documentation this occurred, or the outcome.
# 3 - a grievance was filed by a patient with mental health disorders requesting a new counselor due to transference and anxiety issues. There was no response to the grievance documented.
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Plan of Correction
To address the facility failure to utilize the patient grievance procedure.
1)Goldman Clinic staff will follow
Policy : 715:22 Complaints,Grievance
and appeal procedure , when
addressing participant's concern
2)The Program Director will refer
complaint or grievance to the
appropriate Clinical Supervisor to
address the issue.
3)The Clinical supervisor , after
interviewing all parties concerned,
will informed participant of the
decision. The complaint or grievance
decision and action taken
will be documented by clinical
supervisor on the back of the form.
4)If , the participant desires to
appeal, the Program Director will
interviewing all parties concerned,
will informed participant of the
decision. The complaint or grievance
decision and action taken will be
documented by Program Director on the
back of the form.
5)Program Director will review Patient
records # 1,2,3 compliants and
document outcomes. The outcome will
be document on the forms.
6)Director of Goldman Clinic will be
responsible for implementing and
monitoring compliance to this plan of
correction
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715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
Based on the review of patient records, the facility failed to complete all required laboratory tests as part of the admission process in four of five patient records reviewed.
The findings include:
Twenty eight patient records were reviewed February 18-20, 2014. Five patient records were reviewed for completed laboratory tests as part of the admission process, specifically a tuberculosis Mantoux test (PPD).
Patient records # 1, 2, 3 and 4 did not have documentation of tuberculin Mantoux test having been administered as part of the admission process.
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Plan of Correction
Currently, the LPN's do a PPD test on all admissions and or yearly anniversary day.This documentation is kept in a binder in the medication administration area. The nurse who admits/ read PPD to the client will assure the original PPD documentation goes to the client's counselor to be placed in the medical record after the PPD is read. A copy will remain in the binder in the medication administration area/nurses station.
A LPN will be assign 12 per week to exclusively do PPD's
Physicals should be done on admission and yearly on the client's anniversary date. During the assessment the PPD's should be administer to verify accuracy on the follow up and placement.
This will be monitored by the Clinical Director of Nursing for the Goldman Clinic. She will be monitor this by completing random chart checks to assure the process is working. This monitoring will be a part of the nursing performance improvement plan for this department. These results will be reported quarterly to the Nursing PI Committee.
All nurses will be in serviced on this new process. This started as March the 3rd , 2014.
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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 a review of patient records, the facility failed to conduct an annual evaluation by the in four of eight patient records reviewed.
The findings include:
Twenty-eight patient records were reviewed on February 18-20, 2014. Eight patients were required to receive an annual evaluation.
Patient # 10 was admitted August 18, 2010. The was an annual evaluation completed by the clinician and dated August 16, 2013. However, the evaluation was not signed and dated by the medical director and supervisor until February 14, 2014.
Patient # 12 was admitted in 1988 and was still an active patient at the time of review. The last clinical annual was dated October 10, 2012. An annual evaluation was to have been completed by October 10, 2013 and signed by the medical director.
Patient # 21 was admitted 3/20/03 and was still an active patient at the time of review. At the time of review, the facility failed to conduct an annual clinical evaluation for patient # 21 as the last evaluation was 2/17/12. There was to have been an evaluation for 2//17/2013 and 2/17/2014.
Patient # 23 was admitted 7/11/01 and was still an active patient at the time of review. At the time of review, the facility failed to conduct an annual clinical evaluation for patient # 23 as the last evaluation was 7/13/12. There was to have been an annual evaluation by 7/13/13
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Plan of Correction
To address the facility failure to conduct an annual evaluation:
1 ) All counselors will complete an
annual evaluation documenting an
participant's employment ,
education and training , legal
standing ,substance abuse history ,
ability to manage financial
matters ,physical and emotional
health,fulfillment of treatment
objectives and family and community
supports status. Participants
annual evaluations will be
completed on their admission's
anniversary date.
2) Clinical supervisors will review
annual evaluations prior to the
medical director to determine if
participant's status was fully
documented .
3) The Medical Director will review,
date and sign annual evaluation .
4) Annual evaluations will be placed in
the participants' charts , after the
Medical Director review , date and
sign documents.
5) Clinical supervisors will be
responsible for implementing and
monitoring compliance to this plan
of correction.
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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.
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Observations
Based on a review of patient records, the facility failed to ensure a treatment plan was completed in three of four patient records reviewed.
The findings include:
Twenty eight patient records were reviewed February 18-20, 2014. Four patient records were reviewed specifically for the completion of the treatment plan.
Patient # 1 was admitted December 13, 2013 and did not have a treatment plan developed at the time of the survey.
Patient # 2 was admitted January 7, 2014 and did not have a treatment plan developed at the time of the survey.
Patient # 3 was admitted November 26, 2013 and did not have a treatment plan developed at the time of the survey.
The facility policy is to complete the comprehensive treatment plan within 30 days of admission.
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Plan of Correction
To address facility failure to ensure treatment plan are completed:
1) Clinical supervisors will monitor
counselors ability to develop and
complete treatment plans as stated
in Policy : 911.92
2) Each clinical supervisor will review
(24) charts a month to assess
counselors ability to maintain
quantity and quality of work and
follow Policy: 911.92
3) Patient record # 1,2,3 will
be audited and lack of treatment
plans will be addressed by
completing needed plans counselor(s)
and reviewed by clinical
supervisor(s)
4) Clinical supervisors will
perform a in-sevice on treatment
plan development in team
meeting on 4/1/2014
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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 a review of patient records and discussion with staff, the facility failed to request an exception to provide telephonic counseling services in lieu of receiving required psychotherapy hours onsite as required, or to provide counseling services at all for long periods of time in three of four patient records reviewed.
The findings include:
Twenty eight patient records were reviewed February 18-20, 2014. Four patient records were reviewed for medical exceptions.
Patient # 10 was admitted August 18, 2010. The patient is receiving 6 take home bottles per week for a medical exception. The patient had a face to face counseling session on 6/21/13 and 8/30/13. A telephonic session was documented for 11/15/13. There were other notes by the clinician that telephone counseling had occurred or been scheduled. There was no exception requested or obtained.
Patient # 11 was admitted March 6, 2002. There were no sessions between 11/18/13 and 2/10/14. There was no documentation that an exception request had been requested or obtained.
Patient # 12 was admitted in 1988. There were no counseling sessions documented since 9/20/13. There was no documentation that an exception request had been requested or obtained.
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Plan of Correction
To address facility failure to request an exception to provide telephonic counseling services in lieu of receiving required psychotherapy hours onsite as required, or to provide counseling services at all for long periods of time :
1 ) Clinical supervisors will perform a
in-service on proper procedures for
requesting exceptions on 4/1/2014,
during treatment team.
2) Clinical supervisors will inform
counselors not to provide
telephonic counseling services
without first convening a case
conference with
participant ,counselor and medical
director to assess if there is a
legitamite reason to provide
telephonic counseling because of
patient being medically compromised.
3) A exception will be requested if an
participant is deemed as having a
legitamite reason to provide
telephonic counseling because of
the patient being medically
compromised by counselor.
4) The Medical Director will review
all requests for exceptions.
5) also Clinical supervisors
will monitor compliance to this
plan of correction.
6) The Medical Director will also be
responsible for monitoring and
implementing plan of correction.
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