INITIAL COMMENTS
|
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 19 & 20, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Summit Medical Services was found not to be compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and a plan of correction is due on June 11, 2009.
|
Plan of Correction
|
715.16(a)(2) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(2) The narcotic treatment physician shall make this determination after consultations with staff involved in the patient's care.
|
Observations
Based on a review of 18 patient records patient records, the facility failed to document the narcotic treatment physician's rationale for determining take-home medications in two of four records reviewed.
The findings include:
Patient records # 7 and 15 did not contain the required documentation of the narcotic treatment physician's determination of take-home privileges for patients # 7 and 15. The patient records contained forms that were initiated by facility staff and included documentation by the patients' counselors to address the rationale for take-home considerations for each patient. These forms contained only the physician's signature with no additional documentation provided by the physician.
|
Plan of Correction
The Facility Director will first change the Request for Take-Home Privileges" form to indicate the physician is initiating, justifying and ordering a take-home change.
Both the form and the process will be reviewed with clinical staff in a staff meeting and in a meeting with the Facility Director, Physician and Clinical Supervisor (meetings on 6/2). In both meetings, the Facility Director will go back to the 715 regulations to ensure all parties understand the reason for the change in documentaiton.
At Summit Medical, the Clinical Supervisor reviews each chart after any activity, and will ensure these changes are consistent upon each of these reviews. |
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.
|
Observations
Based on patient record review, the facility failed to document the physician's determination of dose determination in one of eleven records.
The findings include:
Eighteen patient records were reviewed on May 19 and May 20, 2009. Documentation of dosing records were reviewed in eleven records. Patient record # 12 contained documentation that indicated the physicians's assistant had initiated an order to begin the detoxification of patient # 12; the order specified a dose change.
|
Plan of Correction
At Summit Medical, policies and procedures do outline tht the physician, not the physician's assistant, initiates all orders to begin detoxifications.
To prevent any future mistakes in documentation, the Facility Director will first meet with the physicain, the PA and nursing staff to ensure all parties understand the procedures. The phisicain will initiate all future detoxes, then the order can be noted and filed. Both the physician's assistant and head nurse will review the order before it is filed to ensure initials and signatures are in their correct place. |
715.21 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.
|
Observations
Based on a review of patient records, policy and procedure and staff interviews, the facility failed to follow their policy and procedure when they failed to provide documentation that all efforts had been made to retain patients in treatment.
Further, the facility failed to follow policy and procedure as they did not document letters of termination to patients in seven of seven records reviewed.
The findings include:
Eighteen records were reviewed on May 19 and May 20, 2009, nine were reviewed for discharge content. The facility policy specified a letter of termination would be provided to patients prior to an involuntary discharge. Patient records # 4, 5, 6, 10, 11, 12 and 18 did not contain documentation of letters of termination; all were discharged involuntarily.
Additionally, the patient records failed to contain documentation of all efforts utilized to maintain patients # 4, 5, 6, 10, 11, 12 and 18 in treatment.
|
Plan of Correction
It is the belief of Summit Medical staff that the policies and procedures defining all efforts will be made to retain patients in treatment are sound.
To clarify and improve upon the process of an involuntary termination, SMS Facility Director will develop a letter of termination if a patient is to be involuntarity terminated from services. This letter, to be completed by 6/9, will list specific reasons for the detox/termination, what was specificall done to prevent the detox/termination and retain the patient in treatment and notification the patient has a right to appeal. The Clinical Supervisor, in her (at minimun) one time a month review of the chart, will ensure this process is handled consistently as outlined |
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.
|
Observations
Based on the reviews of patient records and policy and procedure and staff interviews. the facility failed to restrict their detoxification of patients to the those areas specified in the regulations.
The findings include:
During the methadone monitoring of May 19 and May 20, 2009, eighteen records were reviewed. These records contained documentation of forms patients are requested to sign at the time of admission. The forms specified reasons that could lead to the termination of patients; these reasons exceeded those cited in the regulations. Reasons for termination included loitering, possession of a lethal weapon, destruction of property, missed counseling sessions and failure to keep financial agreement. Additionally, the facility's patient handbook
also specified a patient could be discharged for reasons that are not specified in the regulations
Further, the patient record review revealed documentation of patient termination that failed to include reasons for termination. Patients # 4, 5, 6, 10, 11, 12 and 18 were all terminated for failure to comply with treatment plans but there was no documentation that identified the specific reasons the patient noncompliance in treatment.
|
Plan of Correction
The Facility Director will first review the policies and procedures and the information patients receive and sign off on at intake on reasons for termination and ensure these reasons match the ones outlined in the 715 regulations. The Facility Director will make necessary changes to do so by 6/9/09.
As part of the letter of termination the Facility Director outlined in the plan of correction on the last citation, The specific reasons for termination will be clarified and better cited. This letter of termination will be implemented and reviewed upon next staff meeting. This letter will include specifically why a person is being detoxed/terminated, what has been done up until that point to maintain this patient in treatment and a note that the patient has a right to appeal the decision for termination.
To ensure the letter of termination is completed correctly and consistently, the clinical supervisor will review the process upon the minimum one time a month clinical chart review. |
715.23(d)(1) 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.
(1) The treatment plan shall identify the behavioral tasks a patient shall perform to complete each short-term goal.
|
Observations
Based on the review of patient records, the narcotic treatment program failed to document treatment plans that were consistent with the patient's treatment needs in twelve of twelve patient records.
The findings include:
Eighteen patient records were reviewed May 19 and 20, 2009. Treatment plans were required in twelve patient records. The narcotic treatment program did not document individualized short and long term goals that were specific to patient treatment needs in the treatment plan in patient records #1, 2, 3, 4, 5, 6, 7, 10, 12. 14, 24 and 28.
|
Plan of Correction
In a review of the treatment plan itself, both the Facility Director and the Clinical Supervisor feels the form used is sound and meets requirements.
The Facility Director has scheduled part of the 6/16 staff meeting as a tutorial for clinical and medical staff to discuss and review problem, goal and action plan formulation in treatment plans. The Facility Director will provide the training on this matter that will include: (a) ensuring the problems defined are related to both recovery and other related topics outlined in other treatment tools such as the case consults, patient questionnaire, psych-socail eval, etc. and are worded in theraputic terms, (b) The goals are defined as a way to solve the specific problem outlined and (c) the action plans are clear, quantitative steps to achieving the goal.
The clinical supervisor will be responsible for ensuring these guidelines are followed through with by the clinical and medical staff. This will be done through the chart reviews the clinical supervisor conducts |