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 June 17 through 20, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Tadiso, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on July 18, 2008.
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Plan of Correction
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715.6(a)(3)(i) 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.
(3) The medical director 's responsibilities include the following:
(i) Supervision of narcotic treatment physicians.
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Observations
Based on a review of personnel documentation presented on June 17, 2008, the narcotic treatment program failed to include in the Medical Director's job description the responsibility of supervising the narcotic treatment physicians.
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Plan of Correction
The Facility Director will revise the job description of the Medical Director to include supervison of narcotic treatment physicians employed by Tadiso Inc. The revised document will be filed in the Medical Directo's Personnel chart signed by the Medical Director and the Facilty Director. All approriate parties will be notified of the role of the Medical Director. |
715.6(a)(3)(ii) 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.
(3) The medical director 's responsibilities include the following:
(ii) Supervision of licensed practical nurses if the narcotic treatment program does not employ a registered nurse to supervise the nursing staff. In addition, the medical director in these instances shall ensure that licensed practical nurses adhere to written protocols for dispensing and administration of medication.
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Observations
Based on a review of personnel documentation presented on June 17, 2008, the narcotic treatment program failed to include in the Medical Director's job description the responsibility of supervising the licensed practical nurses. The job description presented at the time of the review stated that the Medical Director supervises the Director of Nursing. The Director of Nursing is a licensed practical nurse. The program does not employ a registered nurse to supervise the nursing staff.
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Plan of Correction
The Facility Director will revise the job description of the Medical Director to include supervsion of all Nursing Personnel employed by Tadiso Inc. The revised document will be filed in the Personnel chart of the Medical Director and will be signed by the Meidcal Director and the Facility Director. All appropriate parties will be notifed of the supervisory role of the Medical Director. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of eighteen patient records, five were required to have documentation in the patient's record regarding the basis for the determination of current dependence and evidence of a 1 year history of addiction. The narcotic treatment program's physicians failed to document in four of five records, #2, 8, 9 and 17, the basis for the determination of current dependency and evidence of 1 year history of addiction.
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Plan of Correction
The Facility Director will review the 1 year documentation guidelines with all physicians employed by Tadiso Inc. to ensure that the assessment is clearly delineated for eligiblity of methadone services including the current dependency and confirmation of length of addiction. Quality Assurance Personnel will conduct review of files. |
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 a review of eighteen patient records, four were required to have documentation in the patient's record that the admitting narcotic treatment program, with patient consent, contacted the previous narcotic treatment facility for the treatment history. The narcotic treatment program failed to document in three of four records, #7, 9 and 11, that an attempt was made by the program to obtain the patient's consent to contact the previous facility for the treatment history.
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Plan of Correction
All applicants who report previous treatment at a narcotic treatment program will be required to sign release forms to allow Tadiso to request Discharge Summaries from the previous program. Social Services supervisors will fax these release forms and request for discharge summaries to the identified narcotic treatment programs on the day of the applicant's intake. The release forms and fax verification form will be placed in the client's chart. |
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 eighteen patient records, ten were required to have documentation in the patient's record that the narcotic treatment program completed an initial drug-screening urinalysis, conducted by a laboratory approved by CLIA and the Department of Health, prior to the patient's initial medication dose. The narcotic treatment program failed to complete an initial drug-screening urinalysis prior to administering methadone, a narcotic agent, in five of seven records, #1, 2, 8, 9 and 17. The narcotic treatment program used an on-site drug-screen, that is not approved by CLIA and the Department of Health, prior to administering the initial dose of methadone to patients.
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Plan of Correction
The Facility Director will instruct all Intake personnel to ensure that an initial urinalysis will be completed by an approved laboratory on each program applicant. Dates of results will be recorded in the client files. Data Dept. will check at the end of the intake process daily to ascertain if the sample was collected and sent to our contracted laboratory - Clincal Science. |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of eighteen patient records, three were required to have documentation in the patient's record that the narcotic treatment program, with patient consent, transferred the patient files to another narcotic treatment program for continued treatment. The program failed to document in one of three records, #13, that the required information from the patient's file was sent. The consent to release information signed by the patient was restricted to 4 Pa. Code 255.5(b) which does not apply to the release of information between providers. The facility may release any information that the patient gives consent to release.
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Plan of Correction
Social Services supervisor will be responsible for sending required documentation to another narcotic treatment program upon receipt of required consent forms from the receiving narcotic treatment program or with signed consent forms fromthe client who requests that such documentation be sent to another narcotic treatment program. A fox confirmation form will be placed in the client's chart along with the required consent form to indicate that the information has been forwarded. |
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 eighteen patient records, three were required to have documentation in the patient's record that the receiving narcotic treatment program 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. The program failed to document in three of three records, # 3, 7 and 11, that it notified the transferring narcotic treatment program of the patient's admission and initial dose.
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Plan of Correction
Social Services supervisor will fax to transferring narcotic treatment programs a verification of the successful transfer and admission of the client to Tadiso. A copy of this verification form and the fax verification sheet will be placed in the client's chart. |
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.
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Observations
Based on a review of eighteen patient records, seven were required to have annual physical examinations. The program failed to document in three of seven records, #12, 16 and 18, the narcotic treatment physician's annual reevaluation of the patient.
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Plan of Correction
The Facility Director and the Medical Director will ensure that the annual physical examination includes a re-evaluation of the client as to his positive or negative response to treatment and his need for continued treatment. Quality Assurance stall will review file for compliance. |
715.23(b)(11) LICENSURE Patient records
(b) Each patient file shall include the following information:
(11) Counselor notes regarding patient progress and status.
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Observations
Based on a review of eighteen patient records, thirteen were were reviewed to determine compliance with the criteria for progress notes. The program failed to document complete progress notes in ten of thirteen records, #1, 2, 3, 4, 5, 8, 9, 10, 11 and 18. Progress notes failed to consistently document the data, assessment and plan. In addition, the progress notes failed to include information that directly related to the treatment sessions.
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Plan of Correction
Social Services Director and Assistant Director will conduct training session in August 2008 for all counseling staff on the proper DAP progress note documentation. These training sessions will then be conducted quarterly to insure that all new staff are properly trained and veteran staff have refresher training. In addition, the counselors will meet twice a month in group supervision with the Director and Assistant Director to review progress notes and receive feedback and further instruction. |
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 eighteen patient records, eight were were reviewed to determine compliance with the criteria for psychosocial evaluations. The program failed to document complete psychosocial evaluations in four of eight records, #1, 2, 3 and 11. The psychosocial evaluations were mostly historical with patient stated comments rather than a clinical assessment of the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, patient's attitude toward treatment and overall impressions/conclusions. In addition, the psychosocial evaluation in record #1 contained judgmental and critical comments rather than an analysis of the patient supported by documentation gathered in the history
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Plan of Correction
Social Services Director and Assistant Director will conduct training sessions for all counseling staff in August 2008 on the proper documentation of initial and ongoing assessment. These training sessions will be conducted quarterly to insure that all staff are properly trained and will focus on psychosocial reports and clinical impressions. Counselor will meet twice a month in group supervision with the Director and Assistant Director to review psychosocial assessments and receive feedback and further instructions. |
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 eighteen patient records, two were required to have aftercare plans. The program failed to document complete aftercare plans in two of two records, #4 and 5. The aftercare plans failed to include measurable goals with time frames.
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Plan of Correction
Social Services Director and Assistant Director will conduct a training session in August 2008 on the development of Aftercare plans that have measurable goals and time frames. All completed Aftercare plans will be reviewed with the Director or Assistant Director to insure tht the plans have measurable goals and time frames. Plans that are deemed deficient will be returned to the counselor for revision if the client is still in treatment. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of eighteen patient records, seven were required to have annual evaluations. The program failed to document complete annual evaluations in four of seven records, #9, 10, 11 and 14. The annual evaluations failed to address the required areas including employment, education and training, legal standing, substance abuse, financial management abilities, physical and emotional health, fulfillment of treatment objectives and family and community support.
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Plan of Correction
In order to avoid continued confusion regarding the Annual evaluations, the computer format for the annual evaluations will be changed to address the required areas as is currently addressed in the annual case consultations. Each of the required areas will be listed separately to insure that each is addressed by the counselor. Social Service supervisors will review the requirements with counselors.Social Serivce superivisors and Quality Assurance staff will review files to ascertain compliance. |
715.23(d) 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.
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Observations
Based on a review of eighteen patient records, six were required to have a treatment plan. The program failed to document a complete individual treatment and rehabilitation plan that outlines realistic short and long-term treatment goals in six of six records, #1, 2, 3, 8, 9 and 13. The short and long-term goals identified in the individual treatment and rehabilitation plan were identical and did not reflect the needs of the patient identified in the history and psychosocial evaluation.
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Plan of Correction
The social services director and assistant director will review all treatment plans to insure that the initial master treatment plan has at least one goal that was identified as a problem in the psychosocial evaluation or Addiction Severity Index. Plans that are not individualized will be returned to counselors to be revised. These initial treatment plans will also be reviewed in group supervision sessions. |
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 eighteen patient records, six were required to have a treatment plan with identified behavioral tasks. The program failed to document specific behavioral tasks for short-term goals identified in the treatment plan in six of six records, #1, 2, 3, 8, 9 and 13. The behavioral tasks identified for short-term goals in the individual treatment and rehabilitation plan were identical and were not specific for each patient.
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Plan of Correction
The social services director and assistant director will assign counselors to present cases in group supervision along with progress notes and treatment plan updates. This documentation will be reviewed by the group and feedback will be given to the presenting counselor. Feedback and direction will also be given to all group members by the director and assistant director so that all present will learn from the presentation and review. |
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 eighteen patient records, eight were required to have a treatment plan update. The program failed to document complete treatment plan updates in five of eight records, #4, 9, 11, 13 and 14. The treatment plan updates failed to document the review, reevaluation, modification and update of each patient's treatment plan. Previous goals were not addressed and new goals were added with no clarification.
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Plan of Correction
Treatment plan updates will be reviewed in individual supervision sessions as well as in group supervision sessions by the Social Serivce Supervisors with emphasis placed on the areas of deficiency identified in this review.
Training will concentrate how to meet timeframes and identification of realistic goals. Quality Assurance staff will review quarterly to ensure compliance. |