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 July 6-8, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Parkside Recovery 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 August 07, 2010.
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Plan of Correction
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715.7(b) LICENSURE Dispensing or Administering Staffing
(b) Dispensing time shall be prorated for patient census. There shall be sufficient dispensing staff to ensure that all patients are medicated within 15 minutes of arrival at the dispensing area.
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Observations
Based on a review of administrative documentation, observation and staff and patient interviews, the facility failed to ensure that all patients were medicated within 15 minutes of arrival at the dispensing area.
The findings include:
Observation of the dispensing area waiting room was conducted on July 7, 2010 starting at 11:15 AM. Security staff were interviewed regarding the procedure for patients waiting to be medicated as they controlled the flow of the medication dispensing area. Security staff reported that they maintained each patient's ID card and gave it to each patient for the purpose of dosing.
The patient handbook was reviewed on July 8, 2010. The methadone treatment requirements listed on page 4 of the handbook included a statement regarding medication scheduling. It stated "medication is scheduled by appointments which occur after each group or individual session. The client's counselor will distribute identification cards one at a time to each person."
Observation that started at 11:15 AM continued until 11:40 AM. During this time one specific patient was observed waiting. At 11:40 AM, this writer interviewed this specific patient and it was confirmed he had been waiting, at that point, for over 25 minutes to be dosed. In addition, the waiting area was full of patients who were waiting for similar time periods as they had been in group. At about 12:00 noon, another group of patients were released from group. They entered the waiting area to await their respective dosing times.
Several patients in the waiting area reported the process to be dosed can take hours. Medication time is held until after any and all appointments are completed.
Written patient complaints/grievances were reviewed on July 7, 2010. Several of these complaints were regarding the physician not coming at the scheduled time, and then having to wait hours to be dosed. If the patient did not wait, they were told either they would have to come back at 6:45 PM for dosing or they would not be dosed at all.
In discussion with medical and administrative staff, they confirmed that patients must wait until all appointments are completed before they are dosed.
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Plan of Correction
Effective 7/7/10, the program has implemented the use of a second medication window during high peak hours (11am to 1pm, Monday through Friday). This will ensure that there is a sufficient number of dispensing staff available so all patients entering the dispensing waiting area are medicated within 15 minutes of arrival.
The waiting time for patients entering the dispensing waiting area will be monitored and recorded three times per week by Security staff to verify that all patients were medicated within 15 minutes of arrival at the dispensing area.
If the wait time exceeds 15 minutes, Security staff will notify the Program Director immediately. The Program Director will contact the Nursing Supervisor and instruct her to immediately correct the problem.
A monitoring report, documenting Security staff observations will be forwarded to the Program Director and Executive Director for review to ensure the program is adhering to standards for medication the wait time.
Counselors will collaborate with each individual client to establish individualized medicating schedules that correspond with specific therapeutic treatment plan goals.
In the event that there is a delay with the patient's scheduled medical appointment, the appointment will be rescheduled for a time convenient for the patient. The patient will then be given an appointment card with the new appointment time and will go directly to the dispensing waiting area to receive his/her medication.
Staff will be informed of the new procedure in a staff meeting on 8/6/10 and will be trained on the process on 8/23/10 during the DOH Methadone Monitoring Inspection staff training.
The program will be in compliance with this standard by 8/30/10.
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715.9(e) LICENSURE Intake
(e) A narcotic treatment program shall secure a personal history from the patient within the first week of admission. The personal history shall be made a part of the patient record.
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Observations
Based on the review of patient records, the facility failed to complete a personal history within seven days in three of eight patient records.
The findings include:
Sixteen patient records were reviewed July 6-8, 2010. Eight patient records were reviewed for completion of a personal history within seven days of admission. Patient record # 3 was admitted on 4/7/10. A personal history was not completed until 5/6/10. Patient record #6 was admitted on 4/22/10. A personal history was not completed until 5/14/10. Patient record # 15 was admitted January 28, 2010. A personal history was not completed until March 2, 2010.
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Plan of Correction
Effective 7/26/10 the Personal History will be included in all admission packets as part of the intake documentation. It will be completed by the intake specialist as part of the intake process.
The Program Director or designee will review all new intake admission records on a weekly basis to ensure that the personal history has been made a part of the patient record.
The Program Director will re-train clinical staff on standard 715.9(e) during the DOH Methadone Monitoring Inspection staff training on 8/23/10.
The program's compliance with standard 715.9(e) will be monitored and documented though monthly record audits completed by the Program Director and as part of peer review.
The program will be in compliance of this standard by 8/30/10.
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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 the policies and procedures manual and patient records, the narcotic treatment program failed to secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 and 709.28 in 5 of 16 patient records.
Findings:
Patient record # 1 contained a consent to release information form that was missing what information was to be released.
Patient record # 5 contained a consent to release information form that was missing who the information would be released to.
Patient record # 6 contained a consent to release information form that was missing what information was to be released.
Patient record #11, contained a consent to release information form that was missing what information was to be released, a purpose for the consent or to who information would be released to.
Patient record # 19 contained a consent to release information to an emergency contact without identifying who the emergency contact was. There was also a consent to release information to the criminal justice system without any specifics of what part of the system information would receive information.
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Plan of Correction
The Program Director will ensure that the appropriate consent to release information forms for patients #1, 5, 6, 11, and 19 are completed and placed in patient records according to the standard by 8/16/10.
The program's compliance with standard 715.11 will be monitored and documented monitored and documented though monthly record audits completed by the Program Director and as part of peer review. Any deficiencies identified through audits will be reviewed with responsible staff and corrected.
The Program Director will re-train staff on this standard during the DOH Methadone Monitoring Inspection training on 8/23/10.
The program will be in compliance with this standard by 8/30/10.
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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 administrative documentation, a patient interview and a review of a patient's record, the facility failed to rescind take-home privileges according to policy and procedure.
The findings include:
Interviews were conducted with facility patients between 11:50 AM and 2:00 PM on July 7, 2010. During this time, a patient interviewed reported he had lost his take home privileges because he was no longer employed. He reported that he was working with the billing clerk of the facility in ensuring that he continue to have coverage for services, but the clerk was going on vacation. He reported he brought the information in and was told to give it to a clinical supervisor. The patient reported that he was questioned about his work and insurance status, but his answers were not accepted. He was told to bring in the last two pay stubs showing he was no longer employed. The record review showed the supervisor had initiated a take home change report removing the take home privileges and the physician signed it.
In reviewing the patient record it was noted the patient attended all sessions and appointments. The patient was admitted May 7, 2007. The last documented positive urine drug screen was November 2007.
When staff was asked for the reason the patient lost his privileges, they were unable to provide a reason based on the criteria stated in the patient handbook. The patient handbook was reviewed July 8, 2010. Loss of take home privileges is discussed on page 13. The criteria for the loss of privileges includes un-excused absence or missed appointments; urine drug screens positive for illicit drugs; a determination that benefits are no longer deemed to be producing rehabilitative progress; and negative for methadone drug screen. The removal of the patient's take home privileges did not fit into any of these categories.
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Plan of Correction
The Program Director,Program Physician and Clinical Supervisor will review all requests to remove take-home privileges along with all supporting documentation to ensure that the removal of the privilege is limited to the elements contained in the program policy and procedures manual.
As of 8/1/10 the patient's issue has been appropriately addressed by program management. His take-home privileges have been restored.
The Program Director will re-train staff on take home policies and procedures during the DOH Methadone Monitoring Inspection training on 8/23/10.
The program will be in compliance with this standard by 8/30/10.
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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 the review of patient records, the facility failed to complete the annual physical in two of eight patient records.
The findings include:
Twenty-two patient records were reviewed July 6-8, 2010. Eight patient records reviewed required an annual physical exam. Two of the eight were not completed at the time of the monitoring.
Patient # 8 was admitted 05-26-09. The annual physical exam, due by 05-26-10, was not completed at the time of the monitoring.
Patient # 21 was admitted 04-08-08. The annual physical exam, due by 04-08-10, was not completed at the time of the monitoring.
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Plan of Correction
Effective 8/1/10, a list of all annual physicals due will be distributed to the Program Director and Clinical Supervisor at the beginning of each month by the Nursing Supervisor. The Nursing Supervisor will continue to oversee the scheduling of annual physical exams to ensure that they are completed.
In the event that patients refuse to have annual physical examinations, they will be encouraged by the clinical staff to participate and the benefits of doing so will be discussed. Continued refusal will be documented in the patient's record.
The Program Director will monitor the completion of annual physicals though monthly record audits completed by the Program Director and as part of peer review.
The Program Director will re-train staff on standard 715.23(b)(5) during the DOH Methadone Monitoring Deficiency staff debriefing/training on 8/23/10.
The program will be in compliance of this standard by 8/30/10.
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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 the review of patient records, the facility failed to complete case consultations as required in five of twelve patient records.
The findings include:
Twenty two patient records were reviewed July 6-8, 2010. Twelve patient records were reviewed for case consultations. Five patient records did not have the required case consultations.
Patient # 8, admitted May 26, 2009, did not have the annual case consultation due by 05-25-10 at the time of the monitoring.
Patient # 11 was to have quarterly case consultations the first year. the patient was admitted June 11, 2009. There was a consultation documented 09-11-09 and another 03-11-10. A consultation due in December 2009 and another in June 2010 were not documented at the time of monitoring.
Patient # 12, admitted May 22, 2007 did not have the annual case consultation due by 05-22-10 at the time of the monitoring.
Patient # 13, admitted May 7, 2007, did not have the annual case consultation due by 05-07-10 at the time of the monitoring.
Patient # 21, admitted April 8, 2008, did not have the annual case consultation due by 04-8-10 at the time of the monitoring.
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Plan of Correction
The Program Director will re-train staff on standard 715. 23(b)(14) during the DOH Methadone Monitoring Inspection training on 8/23/10.
A tracking form with due dates for completion of all case consultations will be used by the Clinical Supervisor. The supervisor will review due dates in supervision with counselors to ensure that consultations are completed on time.
Timely completion of case consultations will be monitored and documented though monthly record audits completed by the Program Director and as part of peer review. Any deficiencies identified through audits will be reviewed with responsible staff and corrected.
Staff will be re-trained on this standard during the DOH Methadone Monitoring Inspection staff training on 8/23/10.
The program will be in compliance with this standard by 8/30/10.
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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 the review of patient records, the facility failed to ensure the psychosocial evaluations were a clinical assessment of the historical data collected in 8 of 14 records.
The findings include:
Twenty two patient records were reviewed July 6-8, 2010. Fourteen patient records were reviewed for psychosocial evaluations.
Patient record # 1 was admitted May 26, 2010. An evaluation had not been completed at the time of the monitoring.
Patient records # 5, 6, 10, 14, 15, 11 and 17 had psychosocial documents that contained a repeat of the data, patient reported commentary and no clinical assessment.
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Plan of Correction
The Clinical Supervisor will review all new patients' clinical assessments to ensure that all elements in the document are completed and that an individualized clinical assessment is present. The Clinical Supervisor will provide feedback to counseling staff, during supervision, to address any assessments not completed according to standards
The Program Director will also review a sample of completed psychosocial evaluations on a monthly basis to ensure the historical data is being collected and that individualized assessments are present. The Program Director will provide feedback to the Clinical Supervisor regarding the quality and effectiveness of the supervisory reviews.
The Program Director will re-train staff on standard 715. 23(b)(15) during the DOH Methadone Monitoring Inspection staff training on 8/23/10.
The program will be in compliance of this standard by 8/30/10.
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715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on a review of patient records, the facility failed to document follow-up in three of four patient records.
The findings include:
Twenty two patient records were reviewed July 6-8, 2010. Four records required documentation of a follow up attempt or contact. Three patient records contained documentation that the follow up letter was mailed one month after the the document was actually signed.
Patient # 16 was discharged unsuccessfully August 4, 2009. The follow up section was completed and signed on August 6, 2009 stating the follow up letter was sent a month later on September 4, 2009.
Patient # 18 was discharged as absent without leave on March 16, 2010. The follow up section was completed and signed on March 16, 2010 that the follow up letter was sent a month later on April 16, 2010.
Patient # 19 was discharged October 19, 2009. The follow up section was completed and signed on October 19, 2009 stating the follow up letter was sent a month later on November 19, 2009.
There was no way to determine the follow up attempt was actually completed as required.
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Plan of Correction
Medical Records will maintain a worksheet of all patient discharges and verify that follow- up letters are mailed after discharge documentation has been completed and at least thirty days after discharge.
The Clinical Supervisor will review a sample of discharged records on a monthly basis to ensure that the follow-up letters have been sent within appropriate time frame and copies are in the record.
The Program Director will re-train staff on standard 715. 23(b)(24) during the DOH Methadone Monitoring Inspection staff training on 8/23/10.
The program will be in compliance with this standard by 8/30/10.
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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 the review of patient records, the facility failed to complete annual evaluations in accordance with the regulations in five of eight patient records reviewed.
The findings included:
Twenty two patient records were reviewed July 6-8, 2010. Eight patient records required documentation of an annual clinical review. Four were not completed and the fifth was completed by the patient herself.
Patient # 4 was admitted May 8, 2009. An annual clinical evaluation was not documented at the time of the monitoring.
Patient # 8 was admitted May 26, 2009. An annual clinical evaluation was not documented at the time of the monitoring.
Patient # 13 was admitted May 7, 2007. An annual clinical evaluation was not documented for May 2010 at the time of the monitoring.
Patient # 21 was admitted April 8, 2008. An annual clinical evaluation was not documented for April 2010 at the time of the monitoring.
Patient # 20 was admitted April 16, 2007. The annual clinical evaluation was completed by the patient on April 16, 2010. There was no clinical evaluation of the information documented.
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Plan of Correction
Effective 8/1/10, a list of all annual evaluations due for the month will be distributed to the Program Director and Primary Counselors by the Clinical Supervisor, who will monitor the completion of the annual evaluations on a monthly basis.
Completion of annual evaluations will be monitored and documented though monthly record audits completed by the Program Director and as part of peer review. Any deficiencies identified through audits will be reviewed with responsible staff and corrected.
The Program Director will re-train staff on standard 715. 23(c)(1-7) during the DOH Methadone Monitoring Inspection training on 8/23/10.
The program will be in compliance with this standard by 8/30/10.
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