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 28-30, 2010 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 Hospital 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 September 1, 2010.
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Plan of Correction
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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 the review of patient records, the facility failed to transfer the required patient files in two of three patient records.
The findings include:
Fifteen patient records were reviewed July 28-30, 2010. Three of the fifteen patient records required documentation showing the facility transferred the required patient files.
Patient records # 9 and 10 did not have documentation that patient files were sent to the receiving narcotic treatment facilities the patients were referred to, both in May 2010.
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Plan of Correction
The Program Coordinator and Clinical Supervisor will meet with clinical staff for the purpose of re-educating them about materials are required to be forwarded to a receiving narcotic treatment as part of a transfer. The Program Coordinator and/or Clinical Supervisor will sign off on internal transfer documentation materials thereby assuring that the training is being effectively translated into action. |
715.22(a) LICENSURE Patient grievance procedures
(a) A narcotic treatment program shall develop and utilize a patient grievance procedure.
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Observations
Based on the review of administrative documentation and patient records, the facility failed to demonstrate adherence to the grievance procedure in place.
The findings include:
Fifteen patient records were reviewed July 28-30, 2010. Three patient records were reviewed for involuntary termination or transfer. The policy and procedure manual was reviewed July 28, 2010; the policy specified notification of involuntary termination, in writing, to the patient
There was no documentation that the facility notified the patient of the termination and the opportunity to engage the appeal procedure in place.
Patient # 1 was admitted 12-14-09 and involuntarily terminated 1-25-10. There was no documented notice to the patient with the opportunity to appeal.
Patient # 9 was admitted 9-8-06 and involuntarily transferred 5-13-10. There was no documented notice to the patient with the opportunity to appeal.
Patient # 10 was admitted 9-8-06 and involuntarily transferred 5-19-10. There was no documented notice to the patient with the opportunity to appeal.
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Plan of Correction
The Program Coordinator and Senior Therapist will review the program's policies regarding the patient grievance procedure with clinical staff, including the need for documenting these actions in the clinical record. Part of this review will include reminding staff that clients being involuntarily discharged are to receive notification of our intent to involuntarily terminate treatment that includes a) an explanation of the reasons that this non-voluntary discharge is occurring and B) notification of the right to file a grievance. In those instances where the client has not reliably been attending, or has been "sneaking" in and out to avoid therapy, staff often will not be able to discuss the detoxification a priori but will place the client "on hold" at the first opportunity to discuss the situation. Clients failing to attend will be sent formal written notification of their right to dispute program actions. A copy will be placed in the clinical record. Through chart review, the Program Coordinator and Senior Therapist will assure compliance that required documentation is present. |
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 narcotic treatment program failed to document psychosocial evaluations in three of four patient records.
The findings include:
Fifteen patient records were reviewed July 28-30, 2010. Psychosocial evaluations were reviewed in four patient records.
Patient record # 1 was admitted December 14, 2009. An evaluation had not been completed at the time of facility.
Patient records # 5 and 15 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 Program Coordinator will review with counseling staff the timetable for completing psychoscial evaluations. The chart of newly admitted individuals will be reveiwed by the Program Coordinator, Senior Therapist and other administrative personnel approxiamtely 4-5 weeks following admission. It is expected that this routine supervision as well as ongoing training (organized by the Coordinator of Training and Treatment)will ensure that 1) psychosocial evaluations are completed in a timely fashion, and 2) psychosocial evaluations do not represent a recapitulation of the data previously collected. |