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 5-7, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Addiction Medicine and Health Advocate 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 November 4, 2010.
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Plan of Correction
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715.6(a)(2) LICENSURE Physician staffing
(a) A narcotic treatment program shall designate a medical director to assume responsibility for administering all medical services performed by the narcotic treatment program.
(2) When a narcotic treatment program is unable to hire a medical director who meets the qualifications in paragraph (1), the narcotic treatment program may hire an interim medical director. The narcotic treatment program shall develop and submit to the Department for approval a training plan for the interim medical director, addressing the measures to be taken for the interim medical director to achieve minimal competencies and proficiencies until the interim medical director meets qualifications identified in paragraph (1)(i), (ii) or (iii). The interim medical director shall meet the qualifications within 36 months of being hired.
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Observations
Based on a review of administrative documentation and staff interview, the facility failed to ensure at least one hour of physician time a week, on site for, every ten patients for ten of eighteen weeks reviewed.
The findings include:
The physician time sheets were reviewed on October 5, 2010. Eighteen weeks between May 31, 2010 and September 27, 2010 were reviewed for onsite compliance. The facility has a licensed capacity of 500 patients. In an interview with the clinical supervisor on October 6, 2010 regarding the physician hours, and the clinical supervisor acknowledged there would be weeks of non-compliance due to a lack of on-site physician hours.
May 31, 2010 to June 6, 2010 there were 38 onsite physician hours.
June 14, 2010 to June 20, 2010 there were 17 onsite physician hours.
June 21, 2010 to June 27, 2010 there were 10 onsite physician hours.
July 5, 2010 to July 11, 2010 there were 36 onsite physician hours.
July 19, 2010 to July 26, 2010 there were 35 onsite physician hours.
July 27, 2010 to August 2, 2010 there were 38 onsite physician hours.
August 16, 2010 to August 22, 2010 there were 41 onsite physician hours.
August 23, 2010 to August 29, 2010 there were 43 onsite physician hours.
September 6, 2010 to September 12, 2010 there were 21 onsite physician hours.
September 13, 2010 to September 19, 2010 there were 35 onsite physician hours.
This is a repeat deficiency,
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Plan of Correction
AMHA is currently discussing coverage with a physician group practice. It is our intention to utilize this group to provide necessary coverage when needed. As a back-up to this plan, we are also exploring the direct employment of physicians and physician assistants as well as Certified Nurse Practitioners. The Medical Director and Executive Director will be responsible for completion by 11/30/10. |
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 the review of patient records, the facility failed to contact the previous facility for the patient's treatment history in five of six patient records reviewed.
The findings include:
Sixteen patient records were reviewed October 5-7, 2010. Six patient records required contacting the prior treatment facility for the treatment history. Patient records # 5, 6, 8, 12 and 14 did not include documentation of any attempt to obtain the patient's prior treatment history from prior treatment facilities identified during the admission process.
This is a repeat deficiency.
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Plan of Correction
As part of our intake procedure, all intake paperwork is reviewed by the Clinical Coordinator. This paperwork must include documented attempts to secure a treatment history from previous treatment facilities. To assure compliance, the paperwork is not approved, and the patient will not be admitted, until this documentation is part of the intake packet. The intake staff, including the intake counselor and nurse, in addition to the clinical staff, will be trained to understand the improtance and value of obtaining previous treatment histories and the proper filing of such in the record. The Clinical Coordinator will be responsible for compliance and conducting the training. |
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, the facility failed to ensure at least monthly random urine drug screens for three of ten patient records.
The findings include:
Sixteen patient records were reviewed October 5-7, 2010. Nine active patient records were reviewed for monthly urine drug screen results.
Patient record # 3 did not have a urine drug screen on file for July 2010.
Patient record # 4 did not have a urine drug screen on file for August and September 2010.
Patient record # 6 did not have urine drug screen on file for September 2010.
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Plan of Correction
AMHA has an automated drug screen scheduler to insure monthly compliance. The intake nurse, who is responsible for importing and printing the UDS results, will cross check scheduled against completed drug screens each day. If a result is not received for a given patient, she will have the patient complete another UDS. In addition, counselors will monitor the hard copy results and insure that they are filed appropriately in the chart. A review of UDS results is monitored as part of the QA chart review monthly. We will increase the sample size of this review immediately. The Nursing Supervisor and Clinical Coordinator will be responsible for compliance. |
715.23(a) LICENSURE Patient records
(a) A narcotic treatment program shall maintain patient records in conformance with 42 CFR 2.16 and 2.22 (relating to security for written records; and notice to patients of Federal confidentiality requirements) and State statutes and regulations. A narcotic treatment program shall maintain a complete file on the premises for each present and former patient of the narcotic treatment program for at least 4 years after the patient has completed treatment or treatment has been terminated. Files shall be updated regularly so that the information is current.
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Observations
Based on the review of patient records and interviews with clinical staff, the facility failed to ensure that patient records contained the required information and updated regularly with current information in six of sixteen patient records reviewed.
The findings include:
Sixteen patient records were reviewed October 5-7, 2010. Interviews with clinical staff over the three days of monitoring verified that clinical documentation was not completed as required.
Patient # 1 was admitted May 11, 2010; patient record #1 failed to document a treatment plan update that was due by September 30, 2010 and there were no case consultations, due at least quarterly. The last documented service on the record of services was dated August 24, 2010, as was the last documented progress note. The patient had been attending for daily dosing.
Patient # 5 was admitted June 30, 2010. There was no treatment plan update, case consultation, progress notes since July 28, 2010 and no documented service hours since July 2010. The record of service had no documentation since July 28, 2010. The patient had been attending for daily dosing.
Patient # 6 was admitted June 21, 2010. There was no treatment plan update, case consultation, progress notes since August 31, 2010 and no documented service hours since the end of August 2010. The record of service had no documentation since September 2, 2010, when the patient was a "no-show". The patient had been attending for daily dosing.
Patient # 12 was admitted June 28, 2010. There was no treatment plan update, due by September 16, 2010.
Patient # 15 was admitted September 22, 2009 and discharged June 22, 2010. The last treatment plan update was completed February 9, 2010; the last progress note was written April 21, 2010 and the last entry onto the record of services was May 5, 2010 for an individual session for which there was no note.
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Plan of Correction
While we recognize that clinical documentation was an area of non-compliance during this visit, we have implemented a more stringent supervision plan to address the deficiencies. Supervisory staff will be monitoring clinical documentation and compliance with required standards daily with each direct service provider. This will include review of progress notes, case conferences and treatment plans. The Clinical Coordinator and Clinical Supervisor will be responsible for compliance. |
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.
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Observations
Based on a review of patient records and an interview with administrative staff, the facility failed to identify the behavioral tasks a patient was to perform to complete each short term goal identified in four of four patient records reviewed.
The findings include:
Sixteen patient records were reviewed October 5-7, 2010. Four patient records were reviewed specifically for treatment plan completion. Patient records # 1, 5, 6 and 12 did not identify the behavioral tasks for the patient to complete, but rather listed all the behavioral tasks the counselor would be doing. In interviews with the administrative staff, it was noted that they instructed the clinicians to avoid documenting the behavioral tasks for the patient based on a directive by another entity.
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Plan of Correction
We recognize that the both the counselor and the patient have a role to play in the achievement of the treatment plan goals. In the action plan/intervention strategies section of the treatment plan, we will discuss the behavioral tasks the patient will perform, as well as the clinical interventions of the counselor. We will assist counselors in writing their treatment plans to meet all requirements in individual supervision. The Clinical Coordinator and Clinical Supervisor will be responsible for compliance. |