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 June 13-16, 2011 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.
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Plan of Correction
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715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on the review of patient records, administrative documentation and discussion with administrative staff, the facility failed to restrict the determination of a patient's dosing schedule to the medical staff.
The findings include:
Documentation of grievances was reviewed June 13, 2011. Patient # 13 had submitted a grievance dated April 6, 2011 against his counselor of record for having refused him to be medicated on April 5, 2011. The patient's record was reviewed on June 14, 2011. A group note dated April 5, 2011 contained documentation by the counselor of having denied the patient the option of being dosed due to the counselor believing the patient to be impaired. There was no documentation of any medical staff being notified of the possibility of the patient's alleged impairment. The medical note section of the patient's record was also reviewed. There was no documentation by any medical staff consulting on the patient's condition or the need to withhold his dose. The dosing record for the month of April 2011 confirmed the patient was not dosed on April 5, 2011.
Documentation of unusual incidents was reviewed June 13, 2011. An incident was documented on February 9, 2011 of non-medical staff denying a patient to come in and get medicated after she refused to allow security staff to search her. There was no documentation of a specific reason for the search. There was no documentation of medical staff being consulted.
Only a narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. In addition, only dosing staff may determine if a patient is too impaired to be medicated on a particular day.
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Plan of Correction
All clients believed to be impaired by staff members will be evaluated by the dosing or medical staff. Only the dosing or medical staff will make a decision on medicating a client after an evaluation. Only the medical staff shall determine the dosing schedule of any client. The staff will be trained on this policy (715.17)(c)(1)(i-vi) on July 11th, 2011 though the staff will be notified immediately of the regulations. The Nursing Supervisor and Clinical Supervisors will be responsible to monitor the process so that this deficiency does not re-occur. |
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 a review of administrative documentation and discussion with administrative staff, the facility failed to utilize the patient grievance procedure developed.
The findings include:
The policy and procedure manual was reviewed on June 13, 2011. The grievance procedure was reviewed on June 13, 2011. Patient grievances and complaints were reviewed June 14 and 15, 2011. The grievances that were submitted in the month of April failed to have any follow up documentation to demonstrate the procedure established by the project was followed.
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Plan of Correction
A designated clinical supervisor will be responsible for reviewing and acknowledging to the clients' regarding the receipt of the complaint/grievance and offer to meet with the client to discuss the grievance within 72 hours of receipt. All grievances will have documented follow up to the grievance within 48 hours of speaking with client. Incident manager will monitor all follow up of complaints and report to the Program Director weekly regarding all grievances and the follow ups for the week. Program Director will be responsible to monitor this process to ensure this deficiency does not re-occur.
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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 staff, the facility failed to update the records regularly, so the information was not current in fifteen of twenty six patient records.
The findings include:
Twenty six patient records were reviewed June 13-16, 2011. Twenty six patient records were required to be updated regularly so as to be current. Fifteen patient records were not current at the time of the inspection.
Patient # 4 was admitted October 17, 2008. The patient was discharged April 26, 2011 as having completed treatment. An aftercare plan was not updated to reflect the patient's current status at discharge.
Patient # 5, admitted September 8, 2001, did not have the most current annual evaluation in the record at the time of the inspection and the annual physical exam was completed 10 weeks late.
Patient # 6 was admitted June 8, 2009. The patient was discharged as being non-compliant with program rules, but the notice to the patient was not in the patient's record at the time of the inspection.
Patient # 8 was admitted February 1, 2011. There were no progress notes in the patient record at the time of the inspection.
Patient # 9 was admitted March 8, 2008. The last documentation on the record of service was for March 2011.
Patient # 10 was admitted March 26, 2008. The patient required monthly urine drug screens. There was no urine drug screen for May 2011 in the patient record at the time of the inspection. In addition, the patient record did not include an annual case consultation or the annual evaluation for 2011.
Patient # 11 was admitted September 14, 2010. The last documentation on the record of service was for April 2011. The last progress note was dated May 18, 2011.
Patient # 12 was admitted November 12, 2009. An annual case consultation was not completed and placed in the patient record at the time of the inspection. The last documented progress note in the record was dated May 17, 2011. There was no record of services in the patient record at the time of the inspection.
Patient # 16 was admitted July 28, 2003. The last documentation on the record of service was dated April 28, 2011. However, there was documentation the patient participated in her treatment plan review on June 1, 2011 indicating the record of services was not current.
Patient # 19 was admitted September 16, 2010. There were no documented case consultations in the patient record at the time of the inspection. The last documentation on the record of service was April 2011. The last documented progress note was dated May 17, 2011.
Patient # 20 was admitted April 8, 2011. The last documentation of a progress note was April 29, 2011, which was also the last date documented on the record of service.
Patient # 21 was admitted May 19, 2011. There were no progress notes in the record at the time of the inspection.
Patient # 22 was admitted April 19, 2011. The last documented progress note was May 31, 2011, but there was no documented record of service in the patient record at the time of the inspection.
Patient # 23 was admitted June 28, 2006. The last urine drug screen was dated April 29, 2011. The last semi-annual review of the patient's dosage level by the Narcotic Treatment Physician was June 29, 2010. The last progress note in the patient record was dated April 26, 2011.
Patient # 24 was admitted January 24, 2006. The last documented progress note was dated May 4, 2011. There were no progress notes in the patient record between January 26, 2011 and April 20, 2011.
Patient # 26 was admitted December 29, 2003. The last annual case consultation in the patient record was dated December 23, 2009. The last annual evaluation in the patient record was dated December 23, 2009.
Discussions with the facility director and lead clinical supervisor over the the four day inspection determined there was a lapse in the medical records staff responsibility of filing the paperwork after two staff had to take leaves of absences recently.
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Plan of Correction
A Medical Records Clerk will report daily to the Medical Records Supervisor the progress of the day's filing. Three medical records personnel are filing presently and the supervisors will file as needed to keep all records up to date until the fourth clerk comes back from FMLA. Medical Records
Supervisor will be responsible to conduct random audits weekly ensure update of all records. Medical Records Supervisor will make weekly reports to the Program Director regarding the progress of all filing on a weekly basis to ensure this deficiency does not re-occur
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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 in six of ten patient records.
The findings include:
Ten patient records were reviewed for psychosocial evaluations on June 13-16, 2011.
Patient # 1 was admitted April 14, 2011. The psychosocial evaluation repeated the historical data collected from the patient.
Patient # 2 was admitted May 13, 2011. The psychosocial evaluation repeated the historical data collected from the patient.
Patient # 3 was admitted March 10, 2011. The psychosocial evaluation repeated the historical data collected from the patient.
Patient # 11 was admitted September 14, 2010. The psychosocial evaluation repeated the historical data collected from the patient.
Patient # 15 was admitted February 17, 2011. The psychosocial evaluation contained a list of words without any description or evaluation of the historical data collected.
Patient # 17 was admitted February 4, 2011. The psychosocial evaluation contained a list of words without any description or evaluation of the historical data collected.
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Plan of Correction
There will be clinical training for counselors regarding how to properly do a clinical assessment based on the client's historical information. More intense supervision will be given to the counselors who failed to give a proper clinical assessment of the historical data and to all newly hired counselors.
Clinical supervisors will be responsible to monitor/evaluate each psychosocial assessment before it is signed to assure compliance so that this deficiency does not re-occur. Program Director will randomly audit charts to assess the psychosocials to ensure this deficiency does not re-occur.
Training Date: July 11.
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