INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 22-24, 2019, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Narcotic Addict Rehabilitation Program of Thomas Jefferson University was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
|
Plan of Correction
|
715.16(c)(1)(i-iv) LICENSURE Take-home privileges
(c) A narcotic treatment program shall require a patient to come to the narcotic treatment program for observation daily or at least 6 days a week for comprehensive maintenance treatment, unless a patient is permitted to receive take-home medication as follows:
(1) A narcotic treatment program may permit a patient to reduce attendance at the narcotic treatment program for observation to three times weekly and receive no more than a 2-day take-home supply of medication when, in the reasonable clinical judgment of the narcotic treatment physician, which is documented in the patient record:
(i) A patient demonstrates satisfactory adherence to narcotic treatment program rules for at least 3 months.
(ii) A patient demonstrates substantial progress in rehabilitation.
(iii) A patient demonstrates responsibility in handling narcotic drugs.
(iv) A patient demonstrates that rehabilitation progress would improve by decreasing the frequency of attendance for observation.
|
Observations
The facility failed to ensure that all of its patients met the eligibility requirements for the take-home supply of medication the patients were granted.
Patient #4 was admitted for treatment on March 22, 2018, and was an active patient at the time of the inspection. The patient was only eligible for a 2 day take-home supply of medication, but the facility gave the patient a 4 day supply of take-home medication on Novemeber 21, 2018. The 4 day supply included a 2 day supply for the Thanksgiving holiday, but the facility was open for the Thanksgiving holiday.
These findings were reviewed with facility staff as part of the licensing process.
|
Plan of Correction
The medical director has been informed of the need for timely completion of exception forms when extended take home privileges are being requested. New procedures for auditing clinical records have been established by the Coordinator of Treatment, Training & Compliance effective 3/8/2019. These procedures will allow for identification of compliance with respect to this regulation. |
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
The facility failed to ensure that it properly documented all of the dosage changes ordered by the narcotic treatment physicians.
Patient #5 had a dosage increase on January 18, 2019, from 100 mg of methadone to 105 mg of methadone, but the signed order from the physician dated January 18, 2019, did not document the dosage or the dosage increase.
These findings were reviewed with facility staff as part of the licensing process.
|
Plan of Correction
A new chart audit mechanism has been established by the Coordinator of Treatment, Training, & Compliance as of March 8, 2019. Weekly random reviews of clinical records will be conducted, and satisfactory completion of medication change forms, reviewed. Any discrepancies will be brought to the attention of the medical director. |
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.
|
Observations
The facility failed to provide sufficient psychotherapy hours for all of its patients.
Patient #6 was admitted for treatment on may 16, 2017, and was required to receive 2.5 hours of psychotherapy each month for the patient's first 2 years of treatment, but the patient did not receive psychotherapy from May 31, 2018, through August 19, 2018.
These findings were reviewed with facility staff as part of the licensing process.
|
Plan of Correction
It shall be the responsibility of supervisory staff to ensure that patients receive minimally 2.5 hours of psychotherapy per month during their first two years of treatment. Supervisory staff will conduct in-service training on strategies for engaging patients. These strategies will include but are not limited to motivational interviewing, cognitive behavioral strategies, and contingency management. The lack of contact for Patient #6 was the direct result of counselor turnover. In order to minimize the likelihood of extended lapses in treatment, supervisory personnel (n=5) will assume temporary oversight of the vacated caseload. Patient 6 has since been seen for the requisite number of contact hours. |
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.
|
Observations
The facility failed to ensure that it notified transferring narcotic treatment programs that the patients transferred were admitted and dosed at the receiving facility.
Patient #2 transferred into the facility from another narcotic treatment program on August 10, 2018. There was no documentation that the receiving facility notified the transferring facility that the patient was admitted for treatment and that the patient was dosed.
These findings were reviewed with facility staff as part of the licensing process.
|
Plan of Correction
In order to effectively maintain continuity of services, the receiving program must provide written otification when accepting a transfer from another facility. The information sent must include admission date of the patient and date of the initial dose given to the patient by the receiving treatment program. It will be the responsibility of the intake coordinator, operating under the auspices of the Program Coordinator, to ensure compliance. The Program Coordinator will review for a 3 month period all transfers to ensure compliance. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
|
Observations
The facility failed to ensure that annual physical exams were completed within one year of the previous exams in 2 patient files reviewed during the on-site inspection.
Patient #5 was admitted for treatment on February 2, 2016, and was an active patient at the time of the on-site inspection. The patient's most recent physical exam was completed May 26, 2017.
Patient #6 was admitted for treatment on May 16, 2017, and was an active patient at the time of the on-site inspection. The patient had a physical exam completed on May 16, 2017, but the next physical exam was not completed until June 18, 2018.
These findings were reviewed with facility staff as part of the licensing process.
|
Plan of Correction
It is the responsibility of the nursing coordinator and medical director to ensure that patients are scheduled and receive their annual physical examinations. The nursing staff will monitor the need for annual physical exams throughout the year. Each scheduled annual physical exam and the patient's attendance to this appointment will be logged. In the event of no-shows to these appointments, the nursing staff will document these events as well as efforts to reschedule these missed appointments. |
711.92(d) LICENSURE Tx Plan Update
711.92. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
The facility failed to ensure that treatment plans were updated at least once every 60 days in 3 of 8 patient records reviewed during the on-site inspection.
Patient #2 was admitted for treatment on August 8, 2018, and was an active patient at the time of the inspection. The patient's individualized treatment plan was dated August 27, 2018, but the treatment plan update was not completed until November 27, 2018.
Patient #3 was admitted for treatment on February 22, 2018, and was an active patient at the time of the inspection. The patient had a treatment plan update dated September 11, 2018, but the next update was not completed until November 20, 2018.
Patient #6 was admitted for treatment on May 16, 2017, and was discharged on September 11, 2018. The patient had a treatment plan update dated April 6, 2018, but the next update was not completed until August 20, 2018.
These findings were reviewed with facility staff as part of the licensing process.
|
Plan of Correction
It shall be the responsibility of the supervisory staff to ensure that patients are participating in treatment plan updates with their counselors every 60 days. Counselors will update treatment plans with patients every 60 days and supervisors will conduct regular reviews of counselor charts to ensure that the staff are compliant with this regulation.
In the specific instances of patients 2 & 6 were the direct result of staff turnover and case reassignment. Efforts will be made by supervisory staff to ensure timely treatment planning during the interim. |