INITIAL COMMENTS
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This report is a result of an on-site inspection conducted July 21, 22, 23 and 24, 2008 for the approval to use a narcotic agent, specifically methadone, in the treatment of narcotic addiction. This inspection was conducted on 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 was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on August 19, 2008.
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Plan of Correction
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715.10(c) LICENSURE Pregnant patients
(c) Counseling records and other appropriate patients records shall reflect the nature of prenatal support provided by the narcotic treatment program.
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Observations
Based on the review of 20 patient records, records of 2 pregnant women were reviewed to determine the prenatal support provide by the facility, # 13 and 14. One of the 2 records, #13, failed to demonstrate prenatal support by the program.
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Plan of Correction
On the rare occasion when a referral to a more appropriate facility (i.e., Jefferson Family Center) is not feasible, the program's medical director will ensure and document in the medical section of the patient record that the pregnant opiate addicted woman has been referred for prenatal care. The medical director and designees will obtain and file necessary consent so that communication between the patients's other care providers and TJU staff is ongoing post-delivery. Clinical staff will assess attitudes and feelings toward the pregnancy in a non-judgmental fashion thereby providing a safe environment in which these discussions can occur. Self-care issues including diet and abstinence should be a major focus of these conversations which will be documented in the patient record. As part of the routine supervision process, senior administrative staff will review the charts of pregnant patients to ensure that these conversations are being adequately documented. The Coordinator of Treatment and Training will train staff on this issue on 8/14/08. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on the review of 20 patient records, 9 records were reviewed to determine compliance with the requirements for the initial urine drug screen. One of the 9 records reviewed, #16, was admitted in April, 2008. The admission urinalysis was conducted in March 2008, and another urine drug screen was not done in April 2008 at the time of admission. The results of a urinalysis done in March would not be relevant for an April admission.
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Plan of Correction
The medical director will not initiate opiate replacement therapy with any treatment candidate whose intake urinalysis is dated more than three days previous. In such instances, a new urine sample will be requested and sent to the laboratory for rapid analysis. This process was begun on August 4, 2008.
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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 the review of 20 patient records, 4 records were reviewed to determine compliance with the transfer requirements. One of the 4 records, # 9, did not document what records were sent to the receiving facility, only stating "transfer information."
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Plan of Correction
A specific release of information form has been designed for patients being transferred. This newly updated release form specifically lists in detail all information that will be disclosed to the receiving narcotic treatment program. Clinical staff training on the correct use of the newly developed form will be coordinated by the Coordinator of Treatment and Training and will include all senior staff. Administrative supervison, conducted by the Program Coordinator and Senior Clinician, will ensure that therapists transferring patients comply with the new procedure. |
715.23(b)(22) LICENSURE Patient records
(b) Each patient file shall include the following information:
(22) Aftercare plan, if applicable.
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Observations
Based on the review of 20 patient records, 2 were reviewed for aftercare plans. Patient # 18 was discharged as a successful completion of treatment, therefore an aftercare plan was required. However, the facility failed to develop an aftercare plan with the patient upon discharge.
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Plan of Correction
Aftercare plans are routinely prepared with patients who are successfully completing a course of care. Clinical staff has been retrained by the Coordinator of Treatment and Training about the value of aftercare plans and the need for the timely completion of aftercare plans. The Program Coordinator and Program Senior Clinician will be responsible for ensuring that at least two weeks prior to a patient's final dose of medication, clinical staff have completed this form. |
715.23(d)(1) 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.
(1) The treatment plan shall identify the behavioral tasks a patient shall perform to complete each short-term goal.
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Observations
Based on the review of 20 patient records, treatment plan content was reviewed in 6 records. Four of the 6 records did not identify the behavioral tasks for the patient to perform to complete the goals identified, patient records # 2, 4, 12 and 16. Instead, the plan listed objectives for the patients to meet and not specific behavioral tasks to accomplish.
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Plan of Correction
Training to be conducted by the Division of Substance Abuse Program's Coordinator of Treatment and Training will begin in September and will be followed up by training in later months. This training will specifically address the treatment planning process with the goal of reviewing and revising the entire treatment planning process. Identifying behavioral tasks to be completed by the patient will be emphasized in this training. Ongoing on-site supervision and record review provided by the Program Coordinator and Senior Clinician will ensure that clinical staff are developing treatment plans that identify realistic and measurable behavioral tasks for both therapist and patient. |