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 March 4, 5, and 6, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, A.R.S. of Lancaster, LP 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 and a plan of correction is due on April 3, 2008.
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Plan of Correction
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715.8(1)(vi) LICENSURE Psychosocial Staffing
A narcotic treatment program shall comply with the following staffing ratios as established in Chapter 704 (relating to staffing requirements for drug and alcohol treatment activities):
(vi) Outpatients. The counseling caseload for one FTE counselor in an outpatient narcotic treatment program may not exceed 35 active patients.
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Observations
Based on a review of counselor caseloads presented by the Executive Director on March 4, 2008, the facility exceeded the counselor to patient ratio of one full-time equivalent (FTE) counselor for every 35 active patients. Specifically, one counselor had a counselor to patient ratio of 36:1.
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Plan of Correction
The program's Clinical Supervisor is now regularly reviewing counselor caseloads to ensure that no counseling caseload for any full-time equivalent (FTE) counselor exceeds 35 active patients at any one time. Reviews minimally occur at the time of assignment of any new or readmitted patient to ensure compliance with the regulation. |
715.10(c) LICENSURE Pregnant patients
(c) Counseling records and other appropriate patients records shall reflect the nature of prenatal support provided by the narcotic treatment program.
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Observations
Based on a review of patient records on March 4- 6, 2008, the facility failed to ensure that pregnant patients' records reflect the nature of prenatal support provided by the narcotic treatment program in three of three patient records, #8, 10 and 16. Patient record #8 contained a blank prenatal support plan. Documentation reflected in patient record #10 contained inappropriate prenatal support. Lastly, patient record #16 was missing clinical documentation related to the acknowledgement of the patient's pregnancy and prenatal support.
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Plan of Correction
The program's Nurse Practioner now ensures that appropriate supports are provided to all pregnant patients and that these services are adequately documented including, but not limited to, an acknowledgement of the pregnancy and prenatal support and a thoroughly completed prenatal supported plan. |
715.10(f) LICENSURE Pregnant patients
(f) The narcotic treatment program shall ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from a narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment.
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Observations
Based on a review of patient records on March 4- 6, 2008, the facility failed to fully inform each female patient of the possible risk to her and her unborn child of withdrawal from a narcotic drug administered or dispensed by the program for comprehensive maintenance or detoxification treatment. The informed patient consent forms contained in 17 of 17 patient records was missing the above mentioned information pertaining to female patients.
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Plan of Correction
The program's consent to treatment form is being revised to include a statement to better inform each female patient of the possible risk to her and any unborn children of the withdrawal from a narcotic drug administered or dispensed by the program. |
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 a review of patient records on March 4- 6, 2008, the facility failed to maintain confidentiality of patient records in accordance with 42 CFR 2.22 and in four of seventeen records, specifically #2, 6, 7 and 10. In patient record #2, a consent to release information form was signed by the patient but missing all other required information. Consent to release information forms contained in patient records #6, 7 and 10 allowed for the release of urine drug screen results to Legal Aid, probation and managed care, respectively, which exceeds the parameters of 4 Pa. Code 255.5. In addition, facility failed to maintain confidentiality with patient take-home bottles that were returned to the facility. Specifically, returned take-home bottles were observed being thrown into general trash containers in the dispensing area on March 5, 2008 with the patient's name and other identifying information related to packaged medication regulations required by Federal law.
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Plan of Correction
The program's multiple consent to release information forms are being consolidated into a single form that conforms to all state and federal regulations. Additionally, the treatment team is being trained in the proper execution of the new forms and retrained in confidentiality regulations.
Patients now use a black marker to obscure all identifying information when returning used take-out bottles, prior to their disposal.
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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 a review of 17 patient records on March 4- 6, 2008, the facility failed to ensure the completion of random urine drug screens at least monthly in one record, #13. Monthly drug-screening urinalysis was missing in record #13 for the months of December 2007 and January 2008.
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Plan of Correction
Drug screens are randomly scheduled by the computerized dosing system. Program counselors now conduct a review of their caseload's drug testing records during the third week of every month. Any patient found to missing a drug test is scheduled for a test. The Clinical Supervisor is conducting a monthly review of monthly drug tests to ensure conformance with the regulation. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records on March 4-6, 2008, the facility failed to ensure that the narcotic treatment physician determined the proper dosage level for the patients. In 17 of 17 patient records reviewed, the narcotic treatment physician concurred or approved the dosage level for a patient, but did not make the determination as evidenced by the counselor, nurse or CRNP writing the dosage level change medication order that included the actual new dose. The doctor signed an order, "approval."
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Plan of Correction
The program's Medical Director is now documenting his determination of the proper dosage for each patient by writing the full dosage level change order that includes the actual new dose. |
715.16(a)(5) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(5) A narcotic treatment program shall develop written policies and procedures relating to granting and rescinding take-home medication privileges.
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Observations
Based on a review of the narcotic treatment program's policies and procedures manual on March 4, 2008, the facility failed to develop written policies and procedures relating to the rescinding of take-home medication privileges.
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Plan of Correction
The program's Executive Director, Medical Director, and Clinical Supervisor will ensure that written policies and procedures relating to the rescinding of take-home medication are incorporated into the narcotic treatment program's policies and procedures manual. Additionally, the treatment team will be trained in the proper execution of the written policies and procedures. |
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 a review of patient records on March 4- 6, 2008, the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment in 7 of 17 records, specifically #1, 5, 6, 7, 8, 16 and 17.
In record #1, the patient received 1 hour of psychotherapy in November 2007, no hours in December 2007, 1.5 hours in January 2008 and 1.5 hours in February 2008.
Record #5 revealed that the patient received 1.5 hours of psychotherapy in November 2007, no hours in December 2007, .5 hours in January 2008 and 1 hour in February 2008.
In record #6, the patient received no hour of psychotherapy in November 2007, 2 hours in December 2007, no hours in January 2008 and 1 hour in February 2008.
In record #7, the patient received 1 hour of psychotherapy in November 2007, .5 hours in December 2007 and 1 hour in January 2008.
Records #8 and 16 revealed that the patients received 1 hour of psychotherapy in November 2007 and no hours in December 2007.
Lastly, in record #17, the patient received no hours of psychotherapy from November 2007 to January 16, 2008 when the patient was successfully discharged from treatment per the discharge summary.
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Plan of Correction
A monitoring system has been implemented and is being checked daily, weekly and monthly to ensure conformance with the regulation. Training has been conducted with the entire treatment team on this critical issue and is ongoing. The need for the individualization of services above the minimal requirements of the regulation are being emphasized. Counseling engagement and participation are dramatically improved. |
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
Based on a review of patient records on March 4- 6, 2008, the facility failed to document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose in 2 of 17 records, specifically #4 and 10. In addition, patient record #11 revealed that the facility notified the transferring narcotic treatment program two months after the patient was admitted.
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Plan of Correction
A procedure and system has been implemented that ensures that written notification was provided of the admission of the transferred patient to the transferring program. Notification occurs with seven days of the transfer. This notification is now routinely documented in every transferee's treatment file. |
715..23(b)(1) LICENSURE Patient records
(b) Each patient file shall include the following information:
(1) A complete personal history.
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Observations
Based on a review of patient records on March 4- 6, 2008, the facility failed to document a complete personal history in 3 of 17 records, specifically #3, 4 and 6. The personal histories contained either one-word answers with no further clarification or questions left unanswered. In addition, records #8 and 15 revealed that the personal history was not updated when a discharged patient returned to treatment within six months.
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Plan of Correction
Training has been conducted with all program Counselors and Clinical Supervision is routinely monitoring for conformance in this area. Full and complete responses are required to every item on the form and policies governing readmissions are being enforced so that patients admitted after six months must have a completely new biopsychosocial history, interpretive summary, and individualized treatment plan. Those readmitted in less than six months will have their biopsychosocial history updated in a different color ink and will receive a new interpretive summary and a new individualized treatment plan. |
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 a review of patient records on March 4- 6, 2008, the facility failed to document case consultation notes regarding the patient in 2 of 17 records, specifically #11 and 15. In patient record #11 there was no documentation regarding who attended the case consultation. One case consultation note was missing for November 2007 and one failed to be specific to the patient in record #15.
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Plan of Correction
Case consults will be completed quarterly on all patients. If the patient is absent from treatment due to a higher level of care, incarceration, or any other reason, this will be noted in the case consultation. Training has been conducted with the treatment team and ongoing clinical supervision is routinely monitoring this area for compliance. |
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 a review of patient records on March 4- 6, 2008, the facility failed to develop a psychosocial evaluation based on the historical data obtained that included the counselor's clinical impressions in 12 of 17 records, #1, 2, 3, 4, 5, 6, 7, 8, 9, 11, 15 and 16. The psychosocial evaluations was based on current information reported by the patient with no analysis, by the counselor, of the historical data.
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Plan of Correction
Training has been conducted with all program Counselors and Clinical Supervision is routinely monitoring for conformance in completing biopsychosocial evaluations. Full and complete responses are required to every item on the biopsychosocial form including clinical impressions and an analysis of the current and historical data by the counselor. A biopsychosocial is now being completed for every patient admitted to the program that is based on current and historical data obtained from the patient and each biopsychosocial documents the counselor's clinical impression as required by regulation and accreditation standards. |
715.23(b)(22) LICENSURE Patient records
(b) Each patient file shall include the following information:
(22) Aftercare plan, if applicable.
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Observations
Based on a review of patient records on March 4- 6, 2008, the facility failed to document a complete aftercare plan in 1 of 17 records, #17. The aftercare plan did not include personal goals.
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Plan of Correction
Aftercare plans will be completed on all patients and will include both short- and long-term personal goals. Training will be conducted with the treatment team and ongoing clinical supervision is routinely monitoring this area for conformance. |
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 a review of patient records on March 4- 6, 2008, the facility failed to document a complete discharge summary in 2 of 17 records, specifically #7 and 17. The discharge summary in record #7 failed to document the patient's reason for treatment. Record #17 failed to include documentation regarding patient's progress in treatment.
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Plan of Correction
All discharge summaries are now reviewed by the Clinical Supervisor to ensure continuity of care and training has been conducted with the treatment team. Every discharged patient record now routinely includes a discharge summary and each discharge summary is reviewed to ensure that all items are completed, including the reason for treatment, progress in treatment, and reason for discharge as required by regulations and accreditation standards. |
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 a review of patient records on March 4- 6, 2008, the facility failed to document treatment plan updates based on the patient's progress as it relates to the goals stated in the comprehensive treatment plan in 4 of 17 records, specifically #4, 6, 12 and 15. The treatment plan updates failed to address patient specific goals and when new goals were added no interventions or action steps were documented in order to determine measurability. In addition, in record #5 the patient, who was readmitted, had a treatment plan update based on the old comprehensive treatment plan.
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Plan of Correction
Staff training on treatment planning and treatment plan updates has been conducted, although it is ongoing. Clinical supervision is routinely monitoring for conformance with the regulation and ARS is seeking to train treatment team members to interweave assessments, interpretive summaries, treatment plans and progress notes according to best practice guidelines. Treatment plan reviews/updates are reviewed by the Clinical Supervisor to ensure that reviews/updates address patient-specific goals and that when new goals are added that measurable action steps or interventions are documented in order to determine measurability as required by the regulations. All readmitted patients are now required to receive a new treatment plan.
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715.26(b) LICENSURE Security
(b) Each narcotic treatment program shall provide the Department with a specific plan describing the efforts it will make to avoid disruption of the community by its patients and the actions it will take to assure responsiveness to the community. This plan shall designate a staff member to act as community liaison.
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Observations
Based on a review of the narcotic treatment program's policies and procedures manual on March 4, 2008 and discussions with the program director on March 6, 2008, the facility failed to provide the Department with a specific plan describing the efforts it will make to avoid disruption of the community by its patients and the actions it will take to assure responsiveness to the community.
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Plan of Correction
A community relations plan has been written and implemented. The plan describes the organizations and programs efforts to avoid disruption of the community by the patients and the actions to be taken to assure responsiveness to the community being served. |