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 October 31 and November 1, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Kensington Hospital Outpatient Treatment was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of corrections are due on November 21, 2007.
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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 review of physician schedules and staff interviews, the facility failed to ensure at least one hour of physician services per week for every ten patients. The physician was scheduled to work 15 hours per week regardless of the patient census which was 166 patients on October 31, 2007. The facility needed 16.6 hours of physician services.
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Plan of Correction
The Physician Schedule has been revised to reflect 1 hour of services for every ten patients. The Medical Director will monitor the schedule on a weekly basis to assure the appropriate number of physican hours to the Program's census. |
715.9(a)(1) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on the random review of patient records, the facility failed to document that patients # 3, 4, and 5 were 18 years of age prior to the administration of methadone.
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Plan of Correction
Every 2-4 weeks when the counselors meet with the Clinical Supervisor, and at least three client charts will be reviewed in depth and detail at that time. In addition, the Clinical Supervisor has begun using, and will continue to use, a tracking form to review every chart of every counselor every month so as to identify deficiencies in documentation of services provided, and to develop a plan of correction to eliminate these deficiencies. This corrective action has already begun, and will continue until there are no more deficiencies. These chart reviews will include reviews will be used to ensure that all client charts have a photocopy of the photo ID used by the Methadone Maintenance Program. This ID will also confirm that the patient/client is at least 18 years of age prior to the administration of methadone. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on the random review of patient records, the facility failed to document verification of the identity of patient's # 3, 4, and 5 prior to administration of methadone.
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Plan of Correction
M055 POC to verify the identity of the client. : Every 2-4 weeks when the counselors meet with the Clinical Supervisor, and at least three client charts will be reviewed in depth and detail at that time. In addition, the Clinical Supervisor has begun using, and will continue to use, a tracking form to review every chart of every counselor every month so as to identify deficiencies in documentation of services provided, and to develop a plan of correction to eliminate these deficiencies. This corrective action has already begun, and will continue until there are no more deficiencies. These chart reviews will include reviews will be used to ensure that all client charts have a photocopy of the photo ID used by the Methadone Maintenance Program. |
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 the random review of 12 patient records, the narcotic treatment physician failed to document for patients # 5 and 8 a 1 year history of opioid addiction.
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Plan of Correction
This issue was discussed at the Executive Committee of the Medical Staff during the meeting of 11/21/07. Physicians were reminded to document a 1 year history of opioid addiction. The Clinical Supervisor will monitor compliance by conducting monthly random chart reviews. |
715.9(e) LICENSURE Intake
(e) A narcotic treatment program shall secure a personal history from the patient within the first week of admission. The personal history shall be made a part of the patient record.
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Observations
Based on the random review of patient records, the facility failed to ensure the personal history was obtained within the first week of treatment for patients # 2, 3 and 4.
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Plan of Correction
The Program staff was in-serviced on 11/23/07 with regard to obtaining a personal history from the client within the first week of treatment. The Clinical Supervisor will monitor compliance by conducting monthly random chart reviews. |
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 random review of the records for two pregnant patients, the narcotic treatment physician failed to evaluate if treatment should be continued for patient #11 within 3 months of the pregnancy termination.
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Plan of Correction
M083 POC: Within three months after the termination of a pregnancy, the narcotic treatment physician will 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. It will be the responsibility of the Clinical Supervisor, with the help of counselors who have pregnant clients in their caseloads, and administrative support staff who schedule medical appointments, to ensure than this happens. |
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
The facility failed to ensure the confidentiality of the patient's identity when a list of patient's full names was faxed to the Division's office without the specific consent of each patient. Staff confirmed this information was faxed without patient consent.
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Plan of Correction
The Clinical Supervisor in-serviced the Outpatient Treatment staff on the topic of Patient Confidentiality on 11/21/07. Full names will never be used when sending patient related information to other agencies, etc. rather first name, last initial will be used. The Clinical Supervisor will monitor for compliance by conducting monthly random chart reviews. |
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 the random review of patient records, the facility failed to obtain a monthly urine drug analysis. Urine drug screens were missing for patient #3 in June and October 2007; patient #6 in July and August 2007; patient #8 in September 2007; patient #9 in August 2007 and patient #12's last urine drug screen was obtained in July 2007.
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Plan of Correction
M101 POC: The Clinical Supervisor of the facility (Kensington Hospital Outpatient Treatment Services Methadone Maintenance Program) will, henceforth, ensure that the urine screens are completed for all clients every month..
In addition, the Clinical Supervisor has begun using, and will continue to use, a tracking form to review every chart of every counselor every month so as to identify deficiencies in documentation of services provided, which includes a special column to indicate the DATE and the RESULTS of all urine drug screens, so as to ensure that every client receives a UDS every month and that effective action is taken when a UDS is positive.
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715.14(c) LICENSURE Urine testing
(c) A narcotic treatment program shall develop and implement policies and procedures to minimize misidentification of urine specimens and to ensure that the tested specimens can be traced to the donor.
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Observations
The facility failed to develop policy and procedures that ensure accurate tracking of the urine specimen from collection to shipment to the laboratory to minimize misidentification and to ensure the specimen can be traced back to the donor.
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Plan of Correction
M109 POC: The Clinical Supervisor of the facility (Kensington Hospital Outpatient Treatment Services Methadone Program will revise the language of the existing Policy and Procedures Manual to specifically ensure accurate tracking of the urine specimen from collection to shipment to the laboratory, so as to minimize misidentification, and to ensure that the specimen can be traced back to the donor. The Clinical Supervisor will then train all staff who participate in this process so that they consistently follow the correct procedure, and will periodically observe this whole process to ensure that the correct procedure is ALWAYS followed. |
715.16(a)(1) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(1) A narcotic treatment program may give take-home medications only to a patient who the narcotic treatment physician has determined is responsible and able to handle narcotic drugs outside the narcotic treatment program.
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Observations
Based on the random review of patient records, the facility failed to demonstrate if and how the narcotic treatment physician determines if a patient is responsible to handle take home medications.
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Plan of Correction
M127 POC: The narcotic treatment physician will interview the client, review the client's urine drug screens, overall present health and medical record, and ,when in doubt about the motivation or mental health of the client, will ask the client's counselor to join in the discussion with the physician and the client to determine if a patient is ready and responsible to handle take home bottles. It is also the responsibility of the counselor to verify that this is the case, and for the Clinical Supervisor to sign off on this request, BEFORE a request is submitted to the narcotic treatment physician, but it is ultimately the responsibility of the narcotic treatment physician to make the final decision about whether or not it is safe for the client to have one or more THB. No client will be granted take home bottle privileges unless the narcotic treatment physician considers all of the following factors in exercising reasonable clinical judgment about whether a patient is responsible in handling narcotic drugs:
(1) Absence of recent abuse of drugs (narcotic or non-narcotic), including alcohol.
(2) Regular narcotic treatment program attendance.
(3) Absence of serious behavior problems at the narcotic treatment program.
(4) Absence of known recent criminal activity.
(5) Stability of the patient's home environment and social relationships.
(6) Length of time in comprehensive maintenance treatment.
(7) Assurance that take-home medication can be safely stored within the patient's home.
(8) Whether the rehabilitative benefit to the patient derived from decreasing the frequency of attendance outweighs the potential risk of drug diversion.
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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 random review of patient records, the narcotic treatment physician failed to document the rationale for permitting take-home medications.
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Plan of Correction
M131 POC: The "Request For Physician Services" form will be revised by the Clinical Supervisor and reviewed with the narcotic treatment physician by December 7th, 2007, so as to ensure that this physician form clearly documents that the physician consistently and completely documents the rationale for permitting take home medications. The Kensington Hospital Outpatient Treatment Services Clinical Supervisor will monitor charts for compliance both through in depth review of at least three charts when supervising counselors, and through monthly monitoring of all client charts with a chart tracking form. |
715.16(b)(1-8) LICENSURE Take-home privileges
(b) The narcotic treatment physician shall consider the following in determining whether, in exercising reasonable clinical judgment, a patient is responsible in handling narcotic drugs:
(1) Absence of recent abuse of drugs (narcotic or non-narcotic), including alcohol.
(2) Regular narcotic treatment program attendance.
(3) Absence of serious behavioral problems at the narcotic treatment program.
(4) Absence of known recent criminal activity.
(5) Stability of the patient 's home environment and social relationships.
(6) Length of time in comprehensive maintenance treatment.
(7) Assurance that take-home medication can be safely stored within the patient 's home.
(8) Whether the rehabilitative benefit to the patient derived from decreasing the frequency of attendance outweighs the potential risks of drug diversion.
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Observations
The facility failed to rescind take-home privileges for patient #12 who had four months of positive urine drug screens. There was no documentation to indicate that the physician addressed the continuation of take-home privileges.
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Plan of Correction
M137 POC: To ensure that there is no future abuse of the Take Home Medication privilege, and no violations of state regulations by anyone on the hospital staff, no client will be granted take home bottle privileges unless the narcotic treatment physician considers all of the following factors in exercising reasonable clinical judgment about whether a patient is responsible in handling narcotic drugs:
(1) Absence of recent abuse of drugs (narcotic or non-narcotic), including alcohol.
(2) Regular narcotic treatment program attendance.
(3) Absence of serious behavior problems at the narcotic treatment program.
(4) Absence of known recent criminal activity.
(5) Stability of the patient's home environment and social relationships.
(6) Length of time in comprehensive maintenance treatment.
(7) Assurance that take-home medication can be safely stored within the patient's home.
(8) Whether the rehabilitative benefit to the patient derived from decreasing the frequency of attendance outweighs the potential risk of drug diversion.
Therefore, it is especially clear that a client who provides evidence of recent drug abuse through a positive urine drug screen (or through behavior indicating alcohol abuse, intoxication or drug abuse), will be denied any request for take home medication. Clinical supervision, staff training about all pertinent state regulations, and regular review of documented services in client charts by the Clinical Supervisor are all strategies which will be used as often and as much as needed to ensure that there are no future deficiencies in this area.
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715.16(e) LICENSURE Take-home priveleges
(e) With an exception granted under subsection (d), a narcotic treatment program may not permit a patient to receive more than a 2-week take-home supply of medication.
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Observations
The facility failed to adhere to the regulation by allowing patient #12 to come in one time a week and obtain 7 take home bottles without dosing on-site, hence, the patient never is observed taking the methadone. The facility failed to obtain an exception to permit the patient to take all the methadone off-site without being observed.
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Plan of Correction
M149 POC: The Clinical Supervisor will ensure that all state regulations are followed whenever it is necessary for the program to request an exception from the Department of Health to permit a client to take more than six doses of medication (take home bottles), due to a medical condition or any other extreme hardship situation which may justify a request for an exception, and will discuss this request (and all pertinent state regulations and restrictions) with the medical staff before this action is taken. Thus, the Clinical Supervisor will be fully responsible for monitoring this Plan of Correction for compliance with all state regulations and restrictions.
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715.17(c)(1)(i-vi)) 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:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on the random review of 12 patient records, the facility failed to ensure the physician was the person who determined the patient dose changes. The facility utilizes a physician services form that lacks any indication the physician participated in the dose change decision.
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Plan of Correction
M159 POC: The "Request For Physician Services" form will be revised by the Clinical Supervisor and reviewed with the narcotic treatment physician by December 7th, 2007, so as to ensure that this physician services form clearly documents that the physician is the one who makes the dose change decision. The Kensington Hospital Outpatient Treatment Services Clinical Supervisor will monitor charts for compliance both through in depth review of at least three charts when supervising counselors, and through monthly monitoring of all client charts with a chart tracking form, to ensure that the correct procedure is always followed for the documentation of such communication. |
715.18(b) LICENSURE Rehabilitative services
(b) A patient shall also have the opportunity to access legal services.
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Observations
Based on random review of 12 patient records, linkage agreements, interview of staff and the policy manual, the facility failed to demonstrate that the patients have the opportunity to access legal services.
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Plan of Correction
M183 POC: The Director of the Kensington Hospital Detoxification and Intake Unit has committed to obtaining a Letter of Agreement Community Legal Services in order to provide patients/clients with the opportunity to access legal services, and will be responsible for maintaining and monitoring program compliance with this regulation for the unit under her supervision. The Clinical Supervisor for the Methadone Maintenance Program will be responsible for maintaining/monitoring program compliance in the unit under his supervision. Furthermore, clients' right to access legal services will also be indicated in the Methadone Maintenance Program Client Handbook, in both English and Spanish versions, to inform all clients of the opportunity to access legal services. The Clinical Supervisor (in collaboration and cooperation with the Detox/Intake Supervisor) will also take responsibility for the renewal of an appropriate referral agreement with Community Legal Services toward the end of each calendar year for the coming calendar year. |
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 the random review of 12 patient records, the facility failed to ensure that patients # 8, 9 and 11 received psychotherapy according to their documented treatment plan. Patient # 3 received no individual counseling sessions May, June or July, 2007.
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Plan of Correction
M185 POC: Every 2-4 weeks when the counselors meet with the Clinical Supervisor, and at least three client charts will be reviewed in depth and detail at that time. In addition, the Clinical Supervisor has begun using, and will continue to use, a tracking form to review every chart of every counselor every month so as to identify deficiencies in services provided ? to ensure that the following requirements for individualized services are met:
(1) 2.5 hours of psychotherapy per month during the patient's first two years, 1 hour of which will be individual psychotherapy;
(2) Additional psychotherapy as dictated by ongoing assessment of the patient.
This means of supervision will also be used to ensure the documentation of services provided, and to develop a plan of correction to eliminate any deficiencies in such documentation of psychotherapy services provided to clients. These chart reviews will include reviews of closed cases to ensure that follow-up information is included in the record for all discharged clients. Furthermore, staff training will be provided to all counselors to help them to become more organized, motivated and disciplined in their style of providing psychotherapeutic services so as to help clients to solve their problems and meet their needs within this framework for compliance with all regulatory requirements.
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715.20(3) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on the random review of patient records, the facility failed to ensure there was documentation confirming the exact information that was sent to the receiving program for patient # 3 and 5.
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Plan of Correction
M197 POC: The Clinical Supervisor will ensure that staff are provided with the necessary training and supervision to ensure that whenever a client is transferred to another program the information provided will include: the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests and the current status of the patient, and will contain the written consent of the client. The FAX form has been revised to document which materials were sent to the receiving narcotic treatment program. Program staff will also be trained on how to use this new form, and supervised to ensure that they do so in the right way. After the transfer, the confidentiality of patient records remaining at Kensington Hospital will continue to be maintained. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
In three of four patient records reviewed, #2, #3 and #4, the facility failed to provide documentation that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose.
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Plan of Correction
M199: Counseling and administrative support staff will be trained by the Clinical Supervisor on the extreme, potentially life-and-death importance of notifying any transferring narcotic treatment program of the admission of the patient and the date of the initial dose so as to prevent any risk of potentially fatal double dosing of a client, as well as to ensure that there is no unnecessary gap in medication due to miscommunication between the referring and receiving programs. |
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 random patient record review, the facility failed to limit the reasons for termination to the areas permitted by regulation. The facility expanded the reasons for an involuntary termination to include: a patient may be terminated for positive urine drug screens for illicit drugs, missing routine counseling sessions, and/or being financially able to pay and refusing to pay.
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Plan of Correction
M203 POC: Whenever a patient is terminated involuntarily, the Clinical Supervisor of the Kensington Hospital Methadone Maintenance Program will notify the patient in writing of the decision to terminate treatment, and will inform the client of his/her rights at this time so as to ensure due process. Furthermore, no client will be terminated for any reason which is not permitted by regulation. A patient will be terminated involuntarily only if: (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, 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 (a legitimate reason or) cause. (iv)The patient has (consistently, completely, defiantly or egregiously) failed to follow treatment plan objectives. No patient may be terminated solely for positive urine drug screens for illicit drugs; missing routine counseling sessions; and/or being financially unable to pay and refusing to pay. To ensure that this Plan of Correction is implemented, and that there are no future deficiencies or violations of state regulations concerning the proper procedure for involuntary termination of a client, the Clinical Supervisor will carefully consult pertinent state regulations before discharging any client involuntarily, and will provide training and supervision as needed to ensure that others do, too.
If a patient is terminated involuntarily, except a patient who commits or threatens to commit acts of physical violence, will be afforded the opportunity to receive detoxification of at least seven days. The detoxification may take place at the facility or the patient may be referred to another narcotic treatment program or hospital licensed or approved by the Pennsylvania Department of Health.
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715.22(c) LICENSURE Patient grievance procedures
(c) Penalties may not be initiated prior to final resolution with the exception that penalties may be initiated against patients who have committed acts of physical violence or who have threatened to commit acts of physical violence in or around the narcotic treatment program premises.
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Observations
Based on the random review of patient records and staff interviews, the facility failed to notify patients in writing of the decision to terminate treatment, therefore, penalties were initiated without the patient being afforded due process.
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Plan of Correction
M211 POC: WHENEVER A PATIENT IS TERMINATED INVOLUNTARILY, THE CLINICAL SUPERVISOR OF THE KENSINGTON HOSPITAL METHADONE MAINTENANCE PROGRAM WILL NOTIFY THE PATIENT IN WRITING OF THE DECISION TO TERMINATE TREATMENT, AND WILL INFORM THE CLIENT OF HIS/HER RIGHTS AT THIS TIME SO AS TO ENSURE DUE PROCESS. FURTHERMORE, NO CLIENT WILL BE TERMINATED FOR ANY REASON WHICH IS NOT PERMITTED BY REGULATION. A patient will be terminated involuntarily only if: (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, 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 (a legitimate reason or) cause. (iv)The patient has (consistently, completely, defiantly or egregiously) failed to follow treatment plan objectives. No patient may be terminated solely for positive urine drug screens for illicit drugs; missing routine counseling sessions; and/or being financially unable to pay and refusing to pay. To ensure that this Plan of Correction is implemented, and that there are no future deficiencies or violations of state regulations concerning the proper procedure for involuntary termination of a client, the Clinical Supervisor will carefully consult pertinent state regulations before discharging any client involuntarily, and will provide training and supervision as needed to ensure that others do, too.
If a patient is terminated involuntarily, except a patient who commits or threatens to commit acts of physical violence, will be afforded the opportunity to receive detoxification of at least seven days. The detoxification may take place at the facility or the patient may be referred to another narcotic treatment program or hospital licensed or approved by the Pennsylvania Department of Health.
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715.23(b)(3) LICENSURE Patient records
(b) Each patient file shall include the following information:
(3) A complete medical history
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Observations
Based on the random review of patient records and statements by staff, the family medical histories are not obtained as part of the medical history.
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Plan of Correction
M221 POC: Every 2-4 weeks when the counselors meet with the Clinical Supervisor, and at least three client charts will be reviewed in depth and detail at that time. In addition, the Clinical Supervisor has begun using, and will continue to use, a tracking form to review every chart of every counselor every month so as to identify deficiencies in documentation of services provided, and to develop a plan of correction to eliminate these deficiencies. This corrective action has already begun, and will continue until there are no more deficiencies. These chart reviews will include reviews to ensure that family medical histories are included as part of the medical history. When this has not been done, the Clinical Supervisor will ask the narcotic treatment physician to correct this deficiency at the earliest opportunity, and will ALSO ask the client's counselor to ensure that some mention of this information is included in the client's psychosocial history. An in service training was provided on documentation of services to clients on 11/21/07, and follow up trainings will be provided as often as necessary to ensure that clients are always asked for information by the physician and, when necessary, their counselor, about family medical history. |
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 random review of patient records, the facility failed to ensure that all patient records included PPD (Mantoux test for tuberculosis) results, specifically patient records # 1, # 3, # 4, # 5 and # 8 did not have a PPD completed.
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Plan of Correction
M227 POC: The medical staff of the Kensington Hospital Outpatient Treatment Services Methadone Maintenance Program will ensure that all patient records include the results of laboratory tests or other special examinations given by the narcotic treatment program, always and consistently including documented record of the PPD (Mantoux test for tuberculosis) and its results (positive or negative). |
715.23(b)(13) LICENSURE Patient records
(b) Each patient file shall include the following information:
(13) Patient record of services.
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Observations
The facility failed to ensure that four of seven patient records, #4, #5, #7 and #8, included a record of service.
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Plan of Correction
M241 POC: Every 2-4 weeks when the counselors meet with the Clinical Supervisor, and at least three client charts will be reviewed in depth and detail at that time. In addition, the Clinical Supervisor has begun using, and will continue to use, a tracking form to review every chart of every counselor every month so as TO IDENTIFY DEFICIENCIES IN DOCUMENTATION OF SERVICES PROVIDED, INCLUDING A RECORD OF SERVICES PROVIDED, and to develop a plan of correction to eliminate these deficiencies. This corrective action has already begun, and will continue until there are no more deficiencies. These chart reviews will serve to ensure that all charts have a completed, up to date, record of service.
The Clinical Supervisor will provide all Methadone Maintenance Program counselors and support staff with training to ensure that they understand the purpose and correct use of the new tracking forms, and the need and correct procedure for documentation of the Record of Services.
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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 random review of patient records, case consultations were incomplete, late or missing. Specifically, patient #1 had an incomplete disposition, patient #9 case consult was completed four months late, and patient # 11 had no discussion documented of the consult.
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Plan of Correction
M243 POC: The Clinical Supervisor of the facility (Kensington Hospital Outpatient Treatment Services Methadone Maintenance Program) will, henceforth, ensure that the case consultations contain all required information, are done through collaboration , communication and cooperation with other staff involved in helping the client, and are done four times a year for new clients, and at least once a year for all other clients. This will be done through clinical supervision 2-4 times a month (or as often as necessary) and training on the best professional practice for completion of a case consultation. Initial training was provided on the correct procedure for doing and documenting a case consultation, and will continue with each counselor as needed until all case consultations are consistently satisfactory. Every 2-4 weeks when the counselors meet with the Clinical Supervisor, and at least three client charts will be reviewed in depth and detail at that time. In addition, the Clinical Supervisor has begun using, and will continue to use, a tracking form to review every chart of every counselor every month so as to identify deficiencies in documentation of services provided, and to develop a plan of correction to eliminate these deficiencies. This corrective action has already begun, and will continue until there are no more deficiencies. |
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 random review of patient records, the facility failed to ensure that the psychosocial evaluation contained an assessment of the historical data obtained in patient records #1, #3 and #4. Patient #5 had no evaluation completed.
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Plan of Correction
: M245 POC: The Clinical Supervisor of the facility (Kensington Hospital Outpatient Treatment Services Methadone Maintenance Program) will, henceforth, ensure that the psychosocial evaluation contains an assessment of the historical data obtained in patient records. This will be done through clinical supervision 2-4 times a month (or as often as necessary) and training on the best professional practice for completion of a psychosocial history, including careful review of all historical data in the client's chart ? information obtained through previous treatment (previous psychosocial histories, treatment plans, case consults, group and individual progress notes, etc).The Clinical Supervisor provided a special training on the proper, professional completion of a psychosocial history on 11/21/07, and will provide follow-up trainings as needed until all psychosocial histories are truly excellent in the quantity, accuracy and quality of their data.
Every 2-4 weeks when the counselors meet with the Clinical Supervisor, and at least three client charts will be reviewed in depth and detail at that time. In addition, the Clinical Supervisor has begun using, and will continue to use, a tracking form to review every chart of every counselor every month so as to identify deficiencies in documentation of services provided, and to develop a plan of correction to eliminate these deficiencies. This corrective action has already begun, and will continue until there are no more deficiencies.
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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 random review of patient records, the facility failed to ensure the discharge summary contained the required components. The discharge summary for patient #5 did not document what services were offered and had conflicting information with the other file documentation. Patient # 7 was missing the date of discharge, services offered, response to treatment and prognosis.
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Plan of Correction
M261 POC: The Clinical Supervisor of the facility (Kensington Hospital Outpatient Treatment Services Methadone Maintenance Program) will, henceforth, ensure that the discharge summaries contain an assessment of the historical data obtained in patient records. This will be done through clinical supervision 2-4 times a month (or as often as necessary) and training on the best professional practice for completion of a discharge summary. ).The Clinical Supervisor provided a special training on the proper, professional completion of a discharge summary on 11/21/07, and will provide follow-up trainings as needed until all psychosocial histories are truly excellent in the quantity, accuracy and quality of their data. As recommended by our DOH inspector, a special effort will be made to document any progress made during treatment, client's reasons for entering treatment at this time, the reasons for discharge, follow-up plans of the client, and recommendations made by the counselor to the client at the time of discharge when this is possible (i.e. when the client is available and willing to participate in an "exit interview" of this nature).
Every 2-4 weeks when the counselors meet with the Clinical Supervisor, and at least three client charts will be reviewed in depth and detail at that time. In addition, the Clinical Supervisor has begun using, and will continue to use, a tracking form to review every chart of every counselor every month so as to identify deficiencies in documentation of services provided, and to develop a plan of correction to eliminate these deficiencies. This corrective action has already begun, and will continue until there are no more deficiencies.
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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 random review of patient records, the facility failed to include follow-up information regarding three of four patients, # 5, 6 and 8.
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Plan of Correction
M263 POC: : Every 2-4 weeks when the counselors meet with the Clinical Supervisor, and at least three client charts will be reviewed in depth and detail at that time. In addition, the Clinical Supervisor has begun using, and will continue to use, a tracking form to review every chart of every counselor every month so as to identify deficiencies in documentation of services provided, including documentation of follow-up after the client has been discharged, and to develop a plan of correction to eliminate these deficiencies. This corrective action has already begun, and will continue until there are no more deficiencies. THESE CHART REVIEWS WILL INCLUDE REVIEWS OF CLOSED CASES TO ENSURE THAT FOLLOW-UP INFORMATION IS INCLUDED IN THE RECORD FOR ALL DISCHARGED CLIENTS. |
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 random review of patient records, the facility is using a check off form that fails to allow for an accurate evaluation of the patient's annual status.
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Plan of Correction
M267 POC: The Clinical Supervisor of the facility (Kensington Hospital Outpatient Treatment Services Methadone Maintenance Program) will, henceforth, ensure that the annual evaluation contains an assessment of the historical data obtained in patient records. This will be done through clinical supervision 2-4 times a month (or as often as necessary) and training on the best professional practice for completion of an annual history, including careful review of all historical data in the client's chart ? information obtained through previous treatment (previous annual evaluations, treatment plans, case consults, group and individual progress notes, etc).The Clinical Supervisor provided a special training on the proper, professional completion of an annual evaluation on 11/21/07, and will provide follow-up trainings as needed until all psychosocial histories are truly excellent in the quantity, accuracy and quality of their data.
Every 2-4 weeks when the counselors meet with the Clinical Supervisor, and at least three client charts will be reviewed in depth and detail at that time. In addition, the Clinical Supervisor has begun using, and will continue to use, a tracking form to review every chart of every counselor every month so as to identify deficiencies in documentation of services provided, and to develop a plan of correction to eliminate these deficiencies. This corrective action has already begun, and will continue until there are no more deficiencies.
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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 random review of patient records, the facility failed to ensure the patient treatment plan updates included a review of the patient's progress in achieving prior treatment goals, specifically patient record #2, 3, 6 (last updated 3-15-07), 10 and 12.
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Plan of Correction
The Program staff was in-serviced on 11/21/07 to be perform treatment plan updates which need to include a review of the patient's progress in achieving prior treatment goals. The Clinical Supervisor will monitor for compliance by monthly random chart reviews.
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