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, treatment of narcotic addiction. This inspection was conducted on October 26-30, 2009 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 December 5, 2009.
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Plan of Correction
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715.9(a)(3) 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:
(3) Obtain a drug use history and current drug use status of the individual.
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Observations
Based on the review of patient records, the facility failed to obtain a current drug use status in five of ten patient records.
The findings include:
Twenty five patient records were reviewed on October 27-30, 2009. Ten records were reviewed for documentation of current drug use status at the time of admission or re-admission. Patient records # 2, 3, 4, 5 and 9 did not contain documentation of current drug use status in the records as required.
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Plan of Correction
The Medical Director met with all of the program physicians, nurse supervisors and triage nurses, at the medical staff meeting held on 11/18/09. This issue was discussed in detail and physicians were re-trained on policies and procedures relating to the information required at admission or re- admission. Specifically, the importance of obtaining and documenting current drug use status was discussed.
Effective immediately:
Physicians were instructed to include current drug use status for all admissions, including re-admissions. In addition, starting immediately, all charts will be audited by the triage nurses before being returned to medical records to ensure that this information is clearly documented by the physician
The Medical Director will be responsible for assuring the consistency of this procedure. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on a review of administrative documentation during a tour of the dispensing area, the facility failed to ensure the photo identification maintained onsite was updated every three years as required in four of six identification cards reviewed.
The findings include:
A tour of the dispensing area was conducted on October 30, 2009 between 9:30 and 10:15 AM. Patients were observed by this reviewer as they handed their respective photo ID cards to the dispensing nurse prior to being dosed with a narcotic agent. The dispensing nurse placed the photo ID card into an index box card holder. One photo ID box was reviewed and six cards were pulled out to review for date of expiration. Four photo ID cards had expired in 2007 and had not been updated.
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Plan of Correction
Effective 11/30/09 the clinic's census will be sorted by admit date. A clinical supervisor and the security supervisor will begin updating all expired patient identification cards. A new field has been added to the clinic's census with a formula that will automatically calculate for the 3 year expiration date after a new patient is added to the census or whenever an updated id date is added to the census. Moving forward, the clinical supervisors will be responsible for monitoring the census for expired id dates during supervision with their counseling teams. The clinical supervisor will notify the security supervisor, counselor, and patient when it is time for an updated id card. The security supervisor will provide the clinical supervisor with a photo copy of the updated id card. The clinical supervisor will place the updated id card date in the census. The formula will automatically calculate for the next 3 year expiration date. That date will be listed on the census with the patients information. Additionally, the dispensing nurses will check each patient id card for a valid date as the patient presents to the dispensing window. If an expired id card is observed, the dispensing nurse will immediately notify the program director. The program director will monitor this process monthly to assure that all assignments are completed timely |
715.16(a)(2) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(2) The narcotic treatment physician shall make this determination after consultations with staff involved in the patient's care.
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Observations
Based on the review of patient records, the facility, specifically the narcotic treatment physician, failed to document a determination regarding take home medication privileges was made after consultation with staff involved in the patient's care in one of one patient records.
The findings include:
Twenty five patient records were reviewed on October 27-30, 2009. One patient record was reviewed for documentation of take home medication. Patient record # 25 contained an 8 point request form for take home medication bottles, but there was no physician signature to indicate that a review or consultation took place prior to writing an order.
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Plan of Correction
The Medical Director met with all of the program physicians, nurse supervisors and triage nurses, at the medical staff meeting held on 11/18/09.
Parkside Recoveryâ??s take home documentation forms were reviewed and all physicians were re-trained in the procedures required before granting take home privileges. Specifically, physicians were instructed to ensure that, after review and evaluation of the 8 point criteria, they document approval of take-home medications by signing the take home form prior to writing the order for the take home medication.
Effective immediately:
The Medical Director conducts chart audits on a regular basis and will include review for appropriate signatures in the review tool starting immediately.
The Medical Director will be responsible to assure compliance with this requirement.
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715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
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Observations
Based on the review of patient records, the facility, specifically the narcotic treatment physician, failed to document the rationale for permitting take home medication in one of one patient records.
The findings include:
Twenty five patient records were reviewed on October 27-30, 2009. One patient record was reviewed for documentation of take home medication. Patient record # 25 did not have documentation of the physician's rationale for permitting take home medication.
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Plan of Correction
The Medical Director met with all of the program physicians, nurse supervisors and triage nurses, at the medical staff meeting held on 11/18/09.
Parkside Recovery's take homdocumentation forms were reviewed and all physicians were re-trained in the procedures required before granting take home privileges. Specifically, physicians were instructed to ensure that they review the 8 point criteria and if take home privileges are to be granted, they must clearly document on the take home form the rationale for granting the take home privileges. The Medical Director conducts chart audits on a regular basis and will include, checking for documentation of the rationale for granting take home privileges in the review tool.
Effective immediately.
The Medical Director will be responsible to assure compliance. |
715.16(d)(1-3) LICENSURE Take-home privileges
(d) A narcotic treatment program may make exceptions to the requirements in subsection (c) relating to the length of time of satisfactory adherence to narcotic treatment program rules and number of days of take-home medication when, in the reasonable clinical judgment of the narcotic treatment physician, which is documented in the patient record:
(1) A patient has a permanent physical disability.
(2) A patient has a temporary disability.
(3) A patient has an exceptional circumstance such as illness, personal or family crisis, or travel which interferes with the patient 's ability to conform to the applicable mandatory attendance schedules. In all cases, the patient shall demonstrate an ability to responsibly handle narcotic drugs.
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Observations
Based on the review of patient records, the facility failed to ensure the physician completed the exceptional circumstance documentation in one of one patient record reviewed.
The findings include:
Twenty five patient records were reviewed on October 27-30, 2009. One patient record was reviewed for a request regarding an exceptional circumstance take home medication. Patient record # 25 was given an exception for 13 take home medication bottles without documentation by the physician that explained the rationale for the exception.
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Plan of Correction
The Medical Director met with all of the Program Physicians for all sites, as well as the Nurse Supervisors and triage nurses, at the medical staff meeting held on 11/18/09.
The procedures and policies relating to the requirements for take home medication exceptions were discussed in detail.
Effective immediately:
All of the necessary exceptions forms are to be completed along with the take home medication form and then signed by the physician if approved, and kept in the patientâ??s chart. All requests, along with the necessary exception form, for a 13 day supply of take homes can only be approved by the Medical Director, or in the absence of the Medical Director, the Medical Directorâ??s designee. The Medical Director conducts chart audits on a regular basis and will include review for appropriate inclusion and documentation of exceptions in the review tool starting immediately
The Medical Director will be responsible for assuring compliance.
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715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document what materials were sent to the receiving narcotic treatment program in one of one patient record, as required.
The findings include:
Twenty five patient records were reviewed on October 27-30, 2009. One patient record was reviewed for transfer documentation. Patient record # 18 did not have documentation of the material sent to the receiving narcotic treatment program.
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Plan of Correction
Effective 12/1/2009, The dated, signed, and wittnessed, Authorization for Release of Confidential Information for Transfer will list all of the required documents for transfer. Additionally,this release will be attached to the copies of the documents that were faxed along with the fax cover sheet and receipt.This packet will be filed in the correspondence section of the patient's file.
The counselor who is facilitating the transfer will will submit the completed faxed packet to the clinical supervisor. The clinical supervisor will initial and date the cover of the packet, verifying that the packet is complete.
The Assistant Program Director will review the completion of this assignment in supervision with the clinical supervisors. |
715.23(a) LICENSURE Patient records
(a) A narcotic treatment program shall maintain patient records in conformance with 42 CFR 2.16 and 2.22 (relating to security for written records; and notice to patients of Federal confidentiality requirements) and State statutes and regulations. A narcotic treatment program shall maintain a complete file on the premises for each present and former patient of the narcotic treatment program for at least 4 years after the patient has completed treatment or treatment has been terminated. Files shall be updated regularly so that the information is current.
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Observations
Based on the review of patient records and discussion with clinical staff, the facility failed to ensure the patient records were complete and updated regularly with current information in eleven of twenty five patient records reviewed.
The findings include:
Twenty five patient records were reviewed October 27-30, 2009. Twenty five patient records were required to have complete and current information.
Patient records # 2, 3, 4, 5 and 8 were readmitted and the histories were not updated to reflect current information.
Patient records # 2, 3, 4, 5, 8, 9 and 16 did not have psychosocial evaluations in the records.
Patient records # 2, 5, 6, 7, 12 and 21 did not have the required case consultations.
Patient records # 1, 6 and 9 were missing treatment plan updates.
Patient records # 1, 2, 5, 6, 7, 12, 21 and 23 did not have current progress notes.
Patient records # 17, 18, 19 and 23 did not have documented follow up contact attempt as required.
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Plan of Correction
Effective immediately:
* Counselors are instructed to update the histories of all re-admitted consumers,
sign and date their entries, and document the activity in the progress note for that session.
* Counselors are instructed to review the histories of the consumers assigned to them and, during individual sessions, make updates with their consumers as needed.This activity is to be documented in the progress note for that session.
* Each clinical supervisor is directed,during clinical supervisions, to review the re-admitted consumer files for the updates and document the completion of this assignment in a supervision note.
* Each clinical supervisor is directed to review for and verify the updated histories during clinical supervisions with their counselors and throughout the chart auditing process. Supervisors are required to document outcomes ont the audit form and in their clinical supervision notes.
* The Assistant Program Director is responsible for supervising the clinical supervisors with this process and monitoring the outcomes.
* The Program Director will request that the Program Evaluation Department revise the clinical audit to review for updated entries in the psychosocial histories.
Effective 11/9/2009:
* Active patient files are being randomly audited for the determination of missing and incomplete documentation. Counselors are directed to complete all missing and incomplete documentation. The clinical supervisors are required to validate the completeion of this assignment.
Effective 12/7/2009:
* Clinical teams are required to audit, in alphabetical order, all active patient files assigned to each counselors case lists for the determination of missing and incomplete documentation. Counselors are directed to complete all missing and incomplete documentation. The clinical supervisors are required to validate the completeion of this assignment.
Effective 11/2009:
* In a staff meeting, counselors were re-directed to document the completion of treatment plans in their progress notes and to attach a copy of that progress note to the treatment plan when it is submitted to the clinical supervisor.
* Counselors were also directed to complete a note to chart documenting outreach efforts/ follow up contact attempts for the consumers who miss services. Additionally, counselors are required to submit the id cards of awol consumers to their clinical supervisors after every missed session.
* Through the support of the Program Evaluation Department, the management team began utilizing the clinic's complete active census to sort, highlight,track, and verify the timely completion of all required treatment documentation.
* The Program Evaluation Department has developed and provided the clinical supervisors and program managers with templates of weekly reports to be used in verifying that all treatment documents, including progress notes, have been completed by the counselors and reviewed by the clinical supervisors.
The Program Director and Assistant Program Director are required to assure that all clinical assignments are completed and verified.
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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.
The findings include:
Twenty five patient records were reviewed on October 27-30, 2009. Seventeen patient records were reviewed for case consultations.
Patient record # 1, 11, 15, 17, 18, 19 and 24 did not have any staff listed as participating in the consultations, but was written as a progress note of a session with the patient.
Patient records # 2, 5, 6, 7, 12 and 21 did not document the required case consultations at least quarterly.
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Plan of Correction
Effective 12/7/09
* Counseling teams will meet weekly to complete chart audits, in alphabetical order, for each counselor's case list.
* Missing case conferences will be identified through this process and the counselors will have one week to rectify the missing case conference notes.
* All Case Conferences will occurr weekly during clinical and or team supervisions. The staff in attendance will be listed on the note.
Effecective 11/2009
* The clinic's census is now being sorted according to admission dates and utilized as a tracking tool for time sensitive treatment documentation. The due dates are provided for the counselors at least a week in advance. The clinical supervisors and the assistant program director are required to monitor this process weekly during supervision for both counselors and supervisors.
* The assistant program director is required to report on the status of the clinic's case conference submissions weekly.
* The assistant program director is required to submit to the program director a weekly report on the status of all time sensitive treatment documentation. by utilizing the weekly case conference report that was developed by
* The Program Evaluation Department has developed a weekly case conference report to help promote and assure compliance in this area.
* The program director is responsible for assuring compliance in this area.
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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 and administrative documentation, the facility failed to ensure the psychosocial evaluations were a clinical assessment of the historical data collected or completed within the policy-stated 30 days of admission in twelve of fourteen patient records.
The findings include:
The policy and procedure manual was reviewed on October 26, 2009. Twenty five patient records were reviewed on October 27-30, 2009. Fourteen patient records were reviewed for psychosocial evaluations.
Patient record # 1 was admitted 5-8-09. An evaluation was completed 8-21-09.
Patient # 6 was admitted 6-11-09 and the evaluation was completed 10-27-09.
Patient # 24 was admitted 7-1-09 and the evaluation was completed 9-2-09.
Patient # 2 was admitted 3-11-09; patient # 3 was admitted 8-27-09; patient # 4 was admitted 7-23-09; patient # 5 was admitted 1-7-09; patient # 8 was admitted 9-22-09; patient # 9 was admitted 8-10-09 patient # 16 was admitted 7-23-09. There were no psychosocial evaluations in these records.
Patient records # 7, 11, 13 and 24 had psychosocial documents that contained a repeat of the data, patient reported commentary and no clinical assessment of the collected historical data.
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Plan of Correction
Effective immediately:
* The orientation counselor will complete the psychosocial history with the new consumers. The orientation counselor will submit a list of psychosocial completion dates to the program director for these consumers at the end of each week.
* A clinical supervisor will review the psychosocial histories for completion, content, and lanuage, paying close attention to address any, "patient reported", comentary.
* The assigned counselor of record will review the psychosocial history with the consumer and initial and date the bottom of each page for verification.
* The assigned counselor of record will complete the clinical assessment of the collected historical data and submit the assessment to the clinical supervisor.
* The clinical supervisor will review both the psychosocial history and the clinical assessment for timeliness and content. The supervisor will document the completion of this assignment.
The clinical supervisor will document and provide training and supervision around any deficiencies in the above stated areas.
*The assistant program director will review for the completion of the above assignments during supervision with the clinical supervisors.
* The program director will review for the completion of the above assignments during supervision with the assistant program director.
* The program evaluation department will review clinical audits for compliance with the deficiency of late and missing clinical evaluations of the histories and for content.
* The results of the current chart auditing process will direct the completion of the clinical evaluations noted in Observations # M245. |
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, the facility failed to document all of the required information in five of nine patient records.
The findings include:
Twenty five patient records were reviewed October 27-30, 2009. Nine patient records were reviewed for complete discharge summaries.
Patient records # 17, 19, 21, 22, 23 did not specify the reason or reasons the patient entered treatment when they did, but rather documented a general statement of opiate dependence or patient statement of "tired of being tired".
Patient records # 17, 18, 21, 22 and 23 did not document a response to the treatment process, but a general statement focused on the discharge reason or attendance of the patient.
Patient records # 18 and 23 did not document all services offered to the patient during the course of their treatment.
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Plan of Correction
Effective 12/2009
* During clinical team meetings throughout the months of December and January 2010,counselors will receive trainings on the correct process for completing discharge documentation.
Effective immediately and ongoing:
* Clinical supervisors will carefully review the discharge packets and supervise counselors around providing comprehensive and complete responses to the questions.Supervisors will document this process in their supervision notes.
* The program director and assistant program director will randomly audit discharge packects to monitor the counselors and supervisors progess with this assignment.
* During the chart audit process,the program evaluation department will monitor for compliance.
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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, the facility failed to document the progress or lack of progress in achieving the goal statements from the prior treatment plan in eight of fourteen patient records reviewed.
The findings include:
Twenty five patient records were reviewed October 27-30, 2009. Fourteen patient records were reviewed for treatment plan update documentation.
Patient records # 1, 6 and 9 did not have the required treatment plan updates. Patient # 1 had a comprehensive treatment plan completed 6-18-09 and it had not been updated at the time of the review. Patient # had a comprehensive treatment plan dated 8-6-09 and no documented updates. Patient # 9 had a comprehensive treatment plan dated 5-12-09 and it had not been updated.
Patient records # 2, 5, 7, 13, 25 did not document patient progress towards meeting their respective goal statements, but rather contained generalized progress in the program. Goals were dropped without documentation of the reason. Goal status could not be identified in the treatment plan updates.
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Plan of Correction
Effective 11/30/2009, the clinic's census will be sorted weekly, according to admissions dates, and the list of all required treatment documents will be provided to the counselors and clinical supervisors.
Each week, clinical supervisors will be required to utilize and submit the treatment plan tracking report to document the status of all plans due.
The program director and assistant program director are responsible to support, monitor, and report on the status to the executive director and the program evaluation department.
This procss will also be closely monitored via the chart auditing process.
A new client/counselor ssignment process has been designed to assure that the clinicians have support and monitoring to assure that there are no lapses between the comprehensive plan and the updates.
Continued supervision, training, and best practices will occur to assure this process. |