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 March 22-25, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health System 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 April 22, 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 administrative documentation and discussion with facility staff, the facility failed to provide at least one hour of physician time a week, on site for, every ten patients.
The findings include:
Physician time sheets for the months dated January 1, all of February and through March 12, 2010 were reviewed on April 1, 2010. There were insufficient onsite physician hours documented during January, February and March 2010.
The licensed capacity for the facility was 752 patients. The census has been consistently at least 650 patients or more.
During the week starting January 3, 2010 there were 48.25 physician hours documented.
During the week starting January 31, 2010 there were 57 physician hours documented.
During the week starting February 14, 2010 there were 50 physician hours documented.
During the week starting February 21, 2010 there were 39.25 physician hours documented.
During the week starting February 28, 2010 there were 55 physician hours documented.
During the week starting March 7, 2010 there were 51.5 physician hours documented.
In interviews with the facility and the clinic directors, it was determined that a full time physician was on medical leave. In addition, there was documentation noted by a project physician in a patient record reviewed, but there was no documentation presented that this physician was onsite to cover all of the hours required.
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Plan of Correction
The facility physicians will provide physician coverage of 1 hour per week onsite for every ten patients in treatment. In addition, the physician assistant will assist the facility physicians by completing physical exams and or making referrals for clients.
All physician staffing time sheets will be maintained in file as evidence and documentation that enough coverage is being provided to all patients.
The Medical Director will monitor physician's schedules the first of each month to assure that all medical services and coverage are available to clients.
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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 the review of patient records, the facility failed to show current opiate dependency in two of three patient records.
The findings include:
Sixteen patient records were reviewed March 22-24, 2010. Three patient records were reviewed for documentation showing current dependency.
Patient # 9 was admitted to an area hospital for detoxification on November 11, 2009. A urine drug screen was completed at that hospital on November 11, 2009. The results revealed the presence of opiates and documentation in patient record #9 indicated the hospital provided detoxification services to the patient. On November 27, 2009, the patient was admitted to the outpatient narcotic treatment program and started on medication assistance at 30 milligrams.
The documentation by the physician on November 27, 2009 stated that this was the patient's first narcotic treatment and her last use was nine days prior to the admission. Further documentation review revealed the last reported use of an opiate was actually sixteen days prior to the induction into medication assisted treatment. Therefore, there was no current dependency at the time the patient was admitted into medication assisted treatment.
Patient # 13 was admitted to the residential component of the project on March 2, 2010. A urine drug screen was obtained and completed March 3, 2010. The results stated there was the presence of methadone, opiates and benzodiazapine in the patient's system. A written prescription was noted for the patient to have a 20 milligram dose on March 3, 2010. The patient was admitted to the narcotic treatment program on March 4, 2010. The documentation of the physician's determination of the patient's current and at least one year history of dependence was completed and dated March 4, 2010. There was no mention of why the patient had methadone in his system when the urine drug screen was completed. The patient was administered 40 milligrams of methadone on this date.
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Plan of Correction
Effective immediately, any admission to the Methadone Maintenance Program will be evaluated by the Clinic's Physician.. All admissions including clients admitted to residential units, must meet the criteria for current dependency. An initial drug screen showing current opiate dependency will be completed and reviewed by the Physician
The admitting Physician will be responsible for verifying and documenting current drug use status at the time of the admission. The NPHS Education Department will provide training to staff by June 10, 2010 on the Intake process and eligibility for admission.
On a monthly basis the Program Director will review the charts of new admissions to monitor this process is being followed.
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715.16(b)(1-8) LICENSURE Take-home privileges
(b) The narcotic treatment physician shall consider the following in determining whether, in exercising reasonable clinical judgment, a patient is responsible in handling narcotic drugs:
(1) Absence of recent abuse of drugs (narcotic or non-narcotic), including alcohol.
(2) Regular narcotic treatment program attendance.
(3) Absence of serious behavioral problems at the narcotic treatment program.
(4) Absence of known recent criminal activity.
(5) Stability of the patient 's home environment and social relationships.
(6) Length of time in comprehensive maintenance treatment.
(7) Assurance that take-home medication can be safely stored within the patient 's home.
(8) Whether the rehabilitative benefit to the patient derived from decreasing the frequency of attendance outweighs the potential risks of drug diversion.
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Observations
Based on the review of patient records, the facility failed to consider all of the points demonstrating the patient would be responsible in handling narcotic drugs in one of three patient records.
The findings include:
Sixteen patient records were reviewed March 22-24, 2010. Three patient records were reviewed for documentation of consideration of the patient's ability to responsibly handle narcotic drugs. Patient # 2 attended the narcotic treatment facility daily and took a medication bottle of 300 milligrams home every day as the patient is on a split dosing schedule. The patient has consistently provided urine drug screens that were positive for illicit substances and the take home bottles were allowed to continue. In addition, the patient provided at least one urine drug screen that was negative for methadone.
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Plan of Correction
Clients requesting take home medication must meet the full criteria for take home privileges. Clinical Staff and the clinic's Physician will be responsible for reviewing and documenting in the client's chart the progress and compliance of clients handling take home medication. Effective immediately, the physician will rescind take home medication privileges for any client not meeting the full criteria.
By June 15, 2010, the staff will receive training on the criteria for take home medication. It is the responsibility of all clinical staff to monitor take home medication. Clinical Supervisors will monitor take home schedules during weekly supervision.
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715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first two years of treatment in four of six patient records. In addition, the facility has a policy that the counselor is to meet with the patient within three days of admission. The facility failed to document that patients met with their counselor within three days of admission.
The findings include:
Sixteen patient records were reviewed March 22-25, 2010. Six patient records were reviewed for psychotherapy hours during the first two years of treatment.
Patient # 4 was admitted February 12, 2010. The first scheduled session was March 4, 2010. There was only a 50 minute session on March 15, 2010 documented since the patient was admitted.
Patient # 9 was admitted November 27, 2009. There was no documentation of any services provided to the patient.
Patient # 11 was admitted September 25, 2008 and still required at least 2.5 hours per month. The last documentation of therapy services was August 2009.
Patient # 14 was admitted January 22, 2009. The service hours for the prior three months were reviewed on March 24, 2010. The average for the prior three months was 1.5 hours.
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Plan of Correction
Clinical Staff will provide all clients in treatment for the first 2 years with a minimum of 2.5 hours of psychotherapy per month, more as needed. In order for the supervisors to monitor services are being provided, Counselors will continue to provide their clinical supervisors with a weekly schedule of their clients. By June 15, 2010, the Clinical Supervisors will provide training to all staff on psychotherapy service requirements.
Clinical Supervisors will monitor services are being provided by performing weekly supervision and monthly chart reviews.
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715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to ensure that after 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months in two of four patient records.
The findings include:
Sixteen patient records were reviewed March 22-25, 2010. Four patient records were reviewed for psychotherapy services.
Patient # 6 was admitted January 23, 1993 and discharged January 9, 2010. The last documented session was dated February 4, 2009.
Patient # 15 was admitted October 9, 2003 and discharged March 16, 2010. There were no documented sessions the last three months of the patient's treatment.
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Plan of Correction
Clients in treatment for 4 years or more will receive a minimum of one hour of group or individual psychotherapy session per month. All Clinical Staff will attend an in-service training on psychotherapy services needed by May 30, 2010. Clinical Supervisors will review clinical staff weekly schedule to assure all clients are being scheduled for individual or group services. During weekly supervision, Clinical Supervisors will follow up with the client and counselor to make sure the client is receiving services required.
Clinical Supervisors will monitor that this process is being followed by conducting chart reviews on a monthly basis. |
715.21 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.
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Observations
Based on review of patient records and discussion with facility staff, the facility failed to ensure all efforts had been initiated to retain the patient prior to the involuntary termination.
The findings include:
Sixteen patient records were reviewed March 22-25, 2010. Four patient records were reviewed for involuntary and administrative discharges.
Patient # 9 was admitted on November 27, 2009 after being referred by the inpatient unit of the project. The patient was inducted onto methadone by the facility and then was given a termination notice on December 29, 2009 for "failing to comply with residential program" after being discharged from the residential component of the project. The facility did not require patient to go to the residential program as part of the patient's treatment plan.
The facility director reported to this writer that the termination notice was to get the patient's attention, but the patient refused to appeal the notice and instead completed a 19 day detoxification.
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Plan of Correction
Effective immediately, the Clinical Supervisors will review the client's record for written documentation on efforts to engage client in treatment. During weekly team meetings, the Clinical Supervisors will monitor staff on patient retention and termination process. Clinical Supervisors will review charts monthly to monitor and assure that this process in being followed. Beginning June 15, 2010, the Clinical Supervisor will schedule and complete a training session on client retention. |
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 the review of patient records, the facility failed to restrict the reasons for involuntary termination to those reasons allowed by regulation in one of four patient records.
The findings include:
Sixteen patient records were reviewed March 22-25, 2010. Four patient records were reviewed for involuntary, or administrative, discharge.
Patient # 10 was admitted November 14, 2007 and discharged February 3, 2010. On December 30, 2009, a physician order was documented for the patient to begin a financial detoxification. The patient had been on a slow and voluntary taper for awhile before this order was documented. There was no documentation anywhere else in the patient's record indicating there was a financial concern. The clinical documentation and treatment plan updates indicated patient was doing well. Patient was provided with a pregnancy test prior to the initiation of the 21 day detoxification process.
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Plan of Correction
Effective immediately, all clinical staff will follow the restrictions for involuntary termination.
Clinical Supervisors will monitor and review charts monthly to assure all staff are adhering to this process.
By May 15, 2010, the clinical supervisors will provide an in-service training to all staff on the restrictions for patient termination. Clinical staff will not initiate any client termination process without the approval and knowledge of the clinical supervisors. Clients not meeting the restrictions for involuntary termination will remain in treatment. |
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 with a re-evaluation by the physician in one of one patient record reviewed.
The findings include:
Sixteen patient patient records were reviewed March 22-25, 2010. One patient record required a re-evaluation by the physician on the annual physical exam.
Patient # 2 was admitted February 14, 2008. The annual physical exam was completed on March 4, 2010 by the Certified Physician Assistant (PAc), but did not include a re-evaluation by the physician.
This is a repeat deficiency from November 2009.
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Plan of Correction
The annual physical form has been revised. A monthly list is completed at the beginning of each month, identifying clients due for annual physicals and re-evaluations. The Medical Director is responsible for all the re-evaluations. The Medical Director is also responsible for assuring the annual physicals and re-evaluations are being reviewed, signed, and completed.
The Medical Director will complete training by June 15, 2010 on the proper way to complete the new form.
The medical records supervisor and the clinical supervisor will complete monthly chart reviews to monitor this process is being followed as scheduled.
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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 one of one patient records reviewed.
The findings included:
Sixteen patient records were reviewed march 22-25, 2010. One record was reviewed for the annual clinical evaluation.
Patient # 14 was admitted January 22, 2009. An annual clinical evaluation was to have been completed by January 22, 2010. There was no annual evaluation documented at the time of the monitoring survey.
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Plan of Correction
By May 30, 2010, Clinical Supervisors will provide an in-service training on the importance of completing the annual evaluation form on a timely basis. Once the annual evaluation is completed, reviewed, and signed by all clinical staff, it will be filed in the client's record.
Clinical Supervisors will perform monthly chart reviews to monitor this for compliance. |
715.29(5) LICENSURE Exceptions
A narcotic treatment program is permitted, at the time of application or any time thereafter, to request an exception from a specific regulation.
(5) If the exception relates to a specific patient, the narcotic treatment program shall maintain documentation of the exception in the patient 's record.
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Observations
Based on a review of patient records, the facility failed to document an exception when required or follow the stipulations specified in the exceptions granted to patients in two of five patient records.
The findings include:
Sixteen patient records were reviewed March 22-25, 2010. Five records required exceptions.
Patient # 6 was admitted 1-23-1993. Based on documentation, the patient had serious medical issues. The facility requested an exception from the Department for patient to be dosed off-site and for a responsible representative to pick up the medication every two weeks. The most recent exception request approved by the Department had requested the exception from 10-15-08 to 10-15-09. It was also stipulated by the facility that the patient would be seen once monthly and a urine drug screen would be obtained once monthly. The patient's last session was 2-4-2009. Urine drug screens were not completed monthly since the exception was granted, but completed drug screens were done 11-26-08, 2-4-09, 6-09 and the most recent was an oral swab being sent home for the patient to complete and the swab was sent back to the facility on 11-4-09.
Patient # 8 was admitted 5-19-1997 and discharged 1-12-10. Patient had been granted 10 take home bottles without documentation of an exception request submitted to the Department for consideration.
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Plan of Correction
The Medical Director and Clinical Supervisors will review all medical exceptions by May 30, 2010 to assure that stipulations requested on the exceptions are being followed.
Effective immediately, no client will be granted an exception without the proper written documentation and approval from the DOH. The Medical Director and Clinical Supervisors will monitor the client record monthly to assure all exceptions are current and being followed as stipulated. Ongoing training and in-services will be provided to all clinical staff to update them on exceptions process. |