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 May 4-6, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Lebanon Treatment Center was found not to be in compliance with the applicable chapters of 4 PA Code and 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on June 6, 2009.
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Plan of Correction
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of administrative documentation and discussions with administrative staff, the facility failed to ensure physician services at least one hour for every ten patients per week onsite.
The findings include:
Administrative documentation was reviewed on May 4, 2009. This included the physician and physician extender's work schedules. The physician provided no more than 8.5 hours per week and the two physician extenders provided 3 hours each on a weekly basis, bringing the total physician hours to no more than 14.5 hours per week. The current licensed capacity is 245, but the census was an average of 190 patients which required at least nineteen hours of physician hours weekly. The administrative staff interviewed during the monitoring included the facility and regional directors, both reported a continued effort to find another physician to provide the required hours.
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Plan of Correction
As of July 1, an offer has been made and accepted by a qualified physician extender. Awaiting final approval from HR by the end of this week. Discussion with Medical Director regarding increasing hours occured, and Medical Director agreed to increased hours for facility. This process will be monitored by Campus Director. |
715.10(d) LICENSURE Pregnant patients
(d) Within 3 months after termination of pregnancy, the narcotic treatment physician shall enter an evaluation of the patient 's treatment status into her record and state whether she should remain in comprehensive maintenance treatment or receive detoxification treatment.
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Observations
Based on the review of patient records, the facility failed to enter an evaluation of the patient's treatment status within three months after the termination of pregnancy in one of one patient records.
The findings includes:
Fifteen patient records were reviewed on May 5 and 6, 2009. Three records of pregnant or postpartum patients were reviewed and one of these records required an evaluation of the patient's treatment status after the termination of pregnancy, record # 5. The patient was admitted April 5, 2008 and was pregnant on admission. The patient's pregnancy terminated prematurely on April 27, 2008. The physician was to have done an evaluation of her treatment status by July 2008, but this was not completed as required.
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Plan of Correction
Effective June 1, 2009, when a patient's pregnancy has been terminated, the primary counselor will notify the DON electronically through the AMS system. At that time the DON will insert a prompt in the system that will electronically notify nursing prior to ninety days reminding the doctor to perform a post pregnancy evaluation. Clinical staff will be informed of the procedure at the next clinical team, June 4, 2009. The Director Of Nursing (DON) will monitor for compliance. |
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 the review of patient records, the facility failed to maintain the confidentiality of patient record information according to in eight of eight patient records.
The findings include:
Fifteen patient records were reviewed on May 5 and 6, 2009. Eight records were reviewed for compliance with the confidentiality regulations. Eight records contained a signed consent for the local jail in the event the person should be incarcerated. The specific information and purpose was pre-printed to cover all potential scenarios including pregnancy when incarcerated. This would not apply for the men who had signed the consent form. This consent form was obtained from all patients on admission regardless of their legal status.
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Plan of Correction
Effective June 1, 2009, the Clinical Supervisor will instruct all staff to cease the practice of securing signed confidentiality agreements that are not directly related to patients' present care. The Clinical Supervisor will monitor for compliance. |
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 facility failed to restrict the dosage reviews to the physician in two of three patient records.
The findings include:
Fifteen patient records were reviewed on May 5 and 6, 2009. Three records were reviewed for semi-annual dose reviews. Patient records # 5 and 13 contained documentation of the Certified Physician's Assistant (PAC).
Record # 5--Review done by PAC on July 18, 2008 and the physician signed July 19, 2008.
Record # 13--Review done by PAC on March 20, 2009 and the physician signed March 21, 2009.
Only the physician may complete complete the dosing reviews.
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Plan of Correction
A consultation was completed with the medical director, and the result of the consultation is as follows: Effective June 1, 2009, the medical director will bear sole responsibility for reviewing and approving dosage reviews at least twice a year, with reviews occurring at least two months apart. Notification of a dosage evaluation that is due will be the responsibility of the DON, and notification will be electronic through the AMS system. DON will monitor for compliance. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on the review of administrative documentation, the facility failed to restrict dose reviews to the narcotic treatment physician.
The findings include:
The administrative material reviewed included the service agreements for the physician extenders, a Certified Nurse Practitioner (CRNP) and a Physician Assistant (PAC). The service agreement signed by both the CRNP and the PAC contained language that they may "conduct patient dose evaluations to determine effectiveness of their prescribed methadone dose and to determine if dose adjustment is necessary. "
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Plan of Correction
Effective May 28, 2009, updated service agreements have been signed by both the medical director and the physician extenders with corrections to the language that includes "only the medical director may conduct dosage evaluations to determine if dose adjustment is necessary." Completed. |
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 include the physician's rationale for permitting take home medications in two of four patient records.
The findings include:
Fifteen patient records were reviewed on May 5 and 6, 2009. Four records were reviewed for take home permission documentation. Patient records # 12 and 13 did not include documentation of the physician's rationale for granting take home medication.
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Plan of Correction
As of May 28, 2009, the medical director will add his rationale to the case consult completed for the presentation of take home doses at the weekly medical team meeting where the request is presented for approval. Clinical Supervisor will monitor for 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 reason for involuntary termination to those allowed by regulation in one of three patient records.
The findings include:
Fifteen patient records were reviewed on May 5 and 6, 2009. Three records were reviewed as administrative discharges. One record, # 1, contained documentation of an involuntary detoxification.
This patient was threatened with an involuntary detoxification after she requested a taper of her dose against medical advise. She was given a written notice that stated she would not have the option of requesting the taper to cease use. However, further patient record documentation revealed that, in fact, patient # 1 had been put on a specific taper schedule by the physician at her request and it then became an involuntary detoxification order.
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Plan of Correction
Involuntary tapers will be premitted only in the instances of physical violence committed/ threatened; possession of a controlled substance; absence from treatment for a minimum of 3 consecutive days; and failing to follow treatment objectives. The reason for involuntary tapers will be clearly provided to the patient and the opportunity for a fair hearing given. This process will be reviewed in clinical team on September 24, 2009, by clinical Supervisor.
Compliance will be monitored by the Clinic Director
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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 the review of patient records, the facility failed to provide an evaluative assessment of the patient history obtained by clinical staff that included the counselor's clinical analysis of the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, patient's attitude toward treatment and overall impressions in four of four patient records.
The findings include:
Fifteen patient records were reviewed on May 5 and 6, 2009. Psychosocial evaluations were reviewed in four patient records. The psychosocial evaluations of the patient consisted primarily of the repetition of the history and statements reported by the patient in four of four records reviewed for content, patient records # 7, 8, 9 and 13..
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Plan of Correction
As of June 1, at a minimum on a quarterly basis during clinical team meetings, the psychosocial process will be reviewed particularly sample psychosocial for practice with clinical assessment. All psychosocial/ interpretive summary completions will be reviewed for the next 6 months, minimally, by the Clinical Supervisor for sufficient clinical assessment during individual clinical supervision. The Clinical Supervisor will monitor for compliance.
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