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 20-21, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pinnacle Treatment Centers Pa-V, LLC 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 17, 2010.
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Plan of Correction
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of time sheets, census reports and an interview with the facility director, the facility failed to provide at least one hour of physician time per week, on site, for every ten patients.
The findings include:
Census reports and physician time sheets were reviewed on July 20-21, 2010, for the months of March, April, May and June. There were insufficient onsite physician hours in the months of April, May and June, 2010.
During the week of April 26, 2010, the census was 248 patients and there were 24.75 documented physician hours. There were 10.02 clients for each physician hour.
During the week of May 10, 2010, the census was 253 patients and there were 24.25 documented physician hours. There were 10.43 clients for each physician hour.
During the week of May 24, 2010, the census was 253 patients and there were 23.75 documented physician hours. There were 10.65 clients for each physician hour.
During the week of May 31, 2010, the census was 254 patients and there were 24.75 documented physician hours. There were 10.26 clients for each physician hour.
During the week of June 21, 2010, the census was 259 patients and there were 24.75 documented physician hours. There were 10.46 clients for each physician hour.
During the week of June 28, 2010, the census was 256 patients and there were 25.25 documented physician hours. There were 10.13 clients for each physician hour.
The facility director was interviewed on July 21, 2010. The facility director confirmed there were insufficient physician hours in April, May and June 2010.
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Plan of Correction
The facility failed to provide adequate medical/doctor coverage, at least one hour of physician time per week, on site for every ten patients.
The Physician will be onsite to provide coverage for at least one hour per every ten patients and the CRNP will provide additional coverage as needed. The CRNP will monitor the compliance on a daily basis.
It is the responsibility of the Facility Director to monitor the weekly hours of both the physician and the CRNP and ensure compliance in this area. The Facility Director will also ensure that the physician and CRNP are appropriately trained in this area.
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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 and an interview with the facility director, the facility failed to document a personal history from the patient within the first week of admission in five of six patient records.
The finding include:
Sixteen patient records were reviewed on July 20-21, 2010. Six patient records were reviewed for the completion of a personal history from the patient within the first week of admission. The facility did not document a personal history within the first week of admission in patient records # 2, 4, 6, 7 and 8.
Patient # 2 was admitted on March 2, 2010. The personal history was to be completed by March 9, 2010. The personal history completed on March 2, 2010, did not include a history of the patient's family, legal, employment and sexual histories. The information was current information with no historical information documented. A personal history, completed on March 29, 2010 documented a complete personal history.
Patient # 4 was admitted on July 13, 2010. The personal history was to be completed by July 21, 2010. The personal history completed on July 13, 2010, did not include a history of the patient's family, legal, employment and sexual histories.
Patient # 6 was admitted on March 16, 2010. The personal history was to be completed by March 23, 2010. The personal history completed on March 16, 2010, did not include a history of the patient's family, legal, employment and sexual histories. The information was current information with no historical information documented. A personal history, completed on April 15, 2010 documented a complete personal history.
Patient # 7 was admitted on June 15, 2010. The personal history was to be completed by June 22, 2010. The personal history completed on June 15, 2010, did not include a history of the patient's family, legal, employment and sexual histories. The information was current information with no historical information documented. A personal history, completed on July 12, 2010 documented a complete personal history.
Patient # 8 was admitted on April 8, 2010. The personal history was to be completed by April 15, 2010. The personal history completed on April 8, 2010, did not include a history of the patient's family, legal, employment and sexual histories. The information was current information with no historical information documented. A personal history, completed on May 4, 2010 documented a complete personal history.
An interview with the facility director on July 21, 2010 confirmed the personal histories completed within a week of admission listed the required elements but the information was the client's current status only and failed to include the historical data.
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Plan of Correction
The facility failed to document appropriate personal history from patients with in the first week of admission.
The Facility Director will provide training in further development of the personal histories. Clinical supervision will be utilized to evaluate ongoing compliance with additional training as indicated. Ongoing training and compliance will also be monitored by the Facility Director.
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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 and an interview with the facility director, 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 given to the patient by the receiving narcotic treatment program in three of three patient records.
The findings include:
Sixteen patient records were reviewed on July 20-21, 2010. Three patients were transferred into treatment from a narcotic treatment program. Per regulation, 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. 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 given to the patient in records # 2, 8 and 9 .
Patient # 2 was transferred from a narcotic treatment program and admitted into treatment on March 2, 2010. There was no documentation that the facility notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient.
Patient # 8 was transferred from a narcotic treatment program and admitted into treatment on April 8, 2010. There was no documentation that the facility notified the transferring narcotic treatment program the date of the initial dose given to the patient.
Patient # 9 was transferred from a narcotic treatment program and admitted into treatment on March 30, 2010. There was no documentation that the facility notified the transferring narcotic treatment program of the date of the initial dose given to the patient.
The facility director was interviewed on July 21, 2010. The facility director confirmed there was no documentation in patient record # 2 that the facility notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient. The facility director confirmed there was no documentation that the facility notified the transferring narcotic treatment program of the date of the initial dose given to the patient in patient records # 8 and 9.
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Plan of Correction
The facility failed to provide the appropriate documentation of notifying transferring facilities of admission and date of the initial dosing of the patient.
The Facility Director will provide training to both the clinical and medical staff to ensure that all staff are aware of their responsibilities in regards to transfers. It is the responsibility of the medical staff to notify the transferring program upon admission and initial dosing of the patient. The nurse is responsible to contact the transferring program with this information and to document this contact in the medical chart. The clinical intake counselor will provide verification of the transfer in writing, including the admission date and date of initial dose to the transferring facility and will include the fax confirmation in the clinical record. The Facility Director will provide oversight by reviewing clinical intake records and provide supervision for the Intake coordinator as needed.
The physician/CRNP is responsible to provide training to medical staff in this area. The CRNP is responsible for ongoing compliance through review of patient records on the day of admission.
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715.21(1)(i-iv) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
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Observations
Based on a review of the patient handbook and and an interview with the project director, the facility failed to restrict their policy and procedure on involuntary terminations to those areas specified in the regulation.
The findings include:
The patient handbook was reviewed on July 21, 2001. Per regulation, a narcotic treatment program shall develop policies and procedures regarding involuntary terminations. The handbook specified reasons that could lead to the termination of patients. The reasons exceeded those imposed by the regulations. The handbook indicated the reasons for termination included: Patient presents a danger to himself/herself or others, exhibits threatening behaviors, carrying within the clinic any type of weapon. These reasons exceeded those allowed by the regulation.
On July 22, 2010 the project director was interviewed and confirmed that the information listed in the patient handbook exceeded the reasons for involuntary termination that are permitted by the regulation.
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Plan of Correction
The facility's patient handbook had identified the reasons for termination included: Patient presents a danger to him/herself or others, exhibits threatening behaviors, carrying within the clinic any type of weapon. The reasons cited exceeded those allowed by the regulation.
The facility will create an addendum that will be placed in the handbook stating the reasons that are reflected in 715.21(1)(i-iv), including the following reasons: the patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises. The addendum will remain in place until new handbooks are printed. The facility Director is responsible for insuring that the appropriate changes are made.
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715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
Based on the review of patient records and an interview with the facility director, the facility failed to complete all required laboratory tests as part of the admission process in two of six patient records reviewed.
The findings include:
Sixteen patient records were reviewed July 20-21, 2010. Six patient records were reviewed for completed laboratory tests as part of the admission process, specifically a tuberculosis Mantoux test (PPD) and Serological test. The facility did not document completion of the laboratory tests in patient records # 7 and 8.
Patient # 7 was admitted on June 15, 2010. There was no documentation of a Mantoux test in the patient record.
Patient # 8 was admitted on April 8, 2010. There was no documentation of a Serological test in the patient record.
An interview with the facility director on July 21, 2010 confirmed there was no documentation of a Mantoux test in patient record # 7 and that there was no documentation of a Serological test in the patient record # 8.
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Plan of Correction
The facility failed to provide documentation of all required laboratory tests were completed as part of the admission process.
The intake coordinator will ensure that patients have completed admission laboratory testing prior to be scheduled for an intake appointment. The physician will ensure that all needed records are received prior to ordering the patient to begin treatment. The CRNP will audit medical records to ensure that all documentation is present.
The nursing staff will administer the Mantoux test to patients entering treatment, as ordered by the physician and ensure that the appropriate documentation is completed. The CRNP will review the medical records to ensure compliance.
The medical staff will ensure that all patients who are transferring from other facilities have all required serology and Mantoux tests records. Patients whose testing was not transferred will be required to complete the needed tests. The CRNP will again review the medical records to ensure compliance in this area.
The Facility Director will ensure that the Physician/CRNP and Medical Staff are trained and will provide ongoing oversight in this area.
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