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 September 12-14, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Jf Kennedy Community Mh/mr 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.
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Plan of Correction
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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 provide all the required information on consents to release information prior to the patient signing in six of ten patient records.
The findings include:
Twelve patient records were reviewed September 12-14, 2011. Ten patient records were reviewed specifically for compliance with confidentiality.
Five patient records, # 1, 5, 9, 10 and 11 had signed consents for a primary care physician without identifying the primary care physician.
This is a repeat citation from the methadone monitoring inspection dated September 20, 2010.
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Plan of Correction
We have revised our intake process to include printing the person's medical insurance information. This information contains the name of the person's primary care physician. Our administrative staff person will add this information onto the release of information form.
Clinical staff will also utilize this process to update the name of each person's primary care physician at least annually on each person's release of information form. When the physician is not known, this release form will be not be included in the chart until the physician name can be determined. The Clinic Supervisor will provide a formal staff training regarding this procedure on 10/18/2011. The Clinic Supervisor will review all new admissions and annual updates to ensure compliance with this procedure. |
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 review of patient records, and review of the documentation maintained in the dosing area, the facility failed to ensure at least monthly random urine drug screens for three of eleven patients.
The findings include:
Twelve patient records were reviewed September 12-14, 2011. Eleven patient records were reviewed specifically for documentation of monthly urine drug screens. Three patient records did not have documented urine drug screens as required.
Patient # 1 was admitted February 9, 2006. The patient required a random urine drug screen at least monthly. There was no documented urine drug screen for October 2010.
Patient # 3 was admitted December 16, 2009. The patient required a random urine drug screen at least monthly. There was no documented urine drug screen for October 2010 or March 2011.
Patient # 12 was admitted February 10, 2011 as a transfer from another narcotic treatment facility. An admission urine drug screen was completed January 27, 2011. The patient required a random urine drug screen at least monthly. There was no documented urine drug screen for February 2011.
The nurse manager and facility director reviewed urine drug screen documentation and confirmed the above urine drug screens were not completed as required.
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Plan of Correction
We have revised our procedure to ensure monthly urine screening all persons enrolled at our Program. The yellow copy of all UDSs submitted for testing will be maintained in a monthly folder by our nursing staff. This yellow copy will be checked against all UDS reports received from the lab by the 3rd week of each month. The lab will be contacted for copies of any missing screens. In addition, a special note will be included in the chart for each person who was in the hospital, in jail or awol during the month. |
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 a review of patient records, the narcotic treatment program failed to document what materials were sent to the receiving narcotic treatment program in one of one patient records.
The findings include:
Twelve patient records were reviewed September 12-14, 2011. One patient record required documentation of the materials sent to the receiving narcotic treatment program. Patient record # 1 had no documentation of the materials sent to the receiving narcotic treatment program.
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Plan of Correction
Effective immediately, the Clinic Supervisor will ensure that documentation of information sent to the receiving program will be listed on the consent to release of information form and a fax confirmation form will be printed as further evidence that such information was sent to the receiving facility. The Clinic Supervisor is responsible for ensuring compliance.A training will be provided for all staff on October 25, 2011 to ensure that everyone is familiar with this requirement. |