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 November 27, 28, and 29, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Family Center of Thomas Jefferson University Hospital (MATER) 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 corrections are due on December 26, 2007.
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Plan of Correction
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715.8(1)(vi) LICENSURE Psychosocial Staffing
A narcotic treatment program shall comply with the following staffing ratios as established in Chapter 704 (relating to staffing requirements for drug and alcohol treatment activities):
(vi) Outpatients. The counseling caseload for one FTE counselor in an outpatient narcotic treatment program may not exceed 35 active patients.
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Observations
Based on a report by staff that a counselor is currently on medical leave and not actively maintaining the caseload assigned, the ratio is calculated as 36/1, exceeding 35/1 active patients.
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Plan of Correction
POC: Ratios are clearly stated in regulations and the Family Center methadone and licensing manuals. However, a protocol will be included to ensure that, in the event of a temporary staff absence, the clinical supervisor assumes any excess clients that exceed the 35:1 ration after distribution of the caseload.
Caseload have been redistributed to 35:1, as per regulations/standards
Person(s) Responsible: Clinical Supervisor and Program Director
Timeframe for completion: Immediate. |
715.9(a)(1) 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:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on random review of 20 patient records, the facility failed to verify that individuals who were not pregnant were at least 18 years of age prior to admission for treatment.
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Plan of Correction
POC: Proof of verification (birth certificate, non/or driver's license, PP#, Hospital ID bracelet) has been added to the Admission Criteria Form to ensure non-pregnant women were at least 18 years of age.
Perons(s)responsbiel: Program Director and Administration Clinic Coordinator
Timeframe for completion: Immediate |
715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on random review of 20 patient records, the facility failed to verify the individual's identity prior to the administration of an agent, specifically methadone.
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Plan of Correction
POC: Proof of verification of patient's identification (birth certificate, non/or driver's license, PP#, Hospital ID bracelet) has been added to the Admission Criteria Form to individual's identity prior to admistration of an agent, specifically methadone.
Person(s)responsible: Program Director and Administration Clinic Coordinator
Timeframe for completion: Immediate |
715.9(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
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Observations
Based on random review of 20 patient records, the facility failed to contact the previous narcotic treatment program for patients who reported they had received prior treatment.
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Plan of Correction
POC: Upon admission or during the treatment experience, if a patient reports a previous treatment experience, that is not the transferring NTP, the staff will ask for a release of information to be signed, by the patient, to gather this collateral information.
Also, the regulations will be reviewed with all responsible parties in supervision.
Person(s) responsible: Administrative Clinic Coordinator, Clinical Supervisor, and the Primary Counselor
Timeframe for completion: Immediate |
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 random review of 20 patient records, the facility failed to document in the patient records the prenatal support offered and provided by the facility.
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Plan of Correction
Prenatal support and prenatal care are an integral and core component of treatment services to our patients. However, clearly there needs to be a stonger more reference to these services in the individual progress notes. Trainings will be provided, within the following 30 days, to clinical staff to meet compliance with this issue. Also, compliance will be ensured through weekly clinical supervision and quarterly, random chart review
Person(s) responsible: Clinical Supervisor
Timeframe for completion: 30 days |
715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
Based on random review of 20 patient records, the facility released the results of the urine drug screen to the Philadelphia Department of Human Services for patient #2. This disclosure exceeded what may be released under 4 Pa. Code 255.5. In addition, a consent to release information did not specify what information would be disclosed in patient record #1.
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Plan of Correction
POC: Confidentiality has been reviewed with this particular counselor and the proper release of information per 42 CFR.
Also, periodic charts reviews will be performed by the Clinical Supervisor to ensure all confidentiality regulations are being followed.
Person(s) responsible: Clinical Supervisor and Primary Counselors
Timeframe for completion: Immediate |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on random review of 20 patient records, the narcotic treatment physician failed to consult with the physician who completed the physical before determining the initial dose and schedule.
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Plan of Correction
POC: The Medical Director will consult, within two weeks, with the NTPs for Family Center to ensure the protocol, which has been developed by the FC Medical Director and the NTP's; available on every floor of TJUH; and, is required training for all new residents is properly adhered to, complete with the medical consultation process from admission, to induction, to discharge from TJUH to Family Center.
All medical charts will be reviewed upon admission to Family Center and quarterly to ensure protocols are being followed.
Person(s) responsible: Medical Director, Program Director, Nurse Coordinator
Timeframe for completion: Within two weeks |
715.16(c)(3)(i-viii) LICENSURE Take-home privileges
(c) A narcotic treatment program shall require a patient to come to the narcotic treatment program for observation daily or at least 6 days a week for comprehensive maintenance treatment, unless a patient is permitted to receive take-home medication as follows:
(3) A narcotic treatment program may permit a patient to reduce attendance at the narcotic treatment program for observation to one time weekly and receive no more than a 6-day take-home supply of medication when in the reasonable clinical judgment of the narcotic treatment physician, which is documented in the patient record:
(i) A patient demonstrates satisfactory adherence to narcotic treatment program rules for at least 3 years.
(ii) A patient demonstrates substantial progress in rehabilitation.
(iii) A patient demonstrates responsibility in handling narcotic drugs.
(iv) A patient demonstrates that rehabilitation progress would improve by decreasing the frequency of attendance for observation.
(v) A patient demonstrates no major behavioral problems.
(vi) A patient is employed, is actively seeking employment, attends school, is a homemaker or is considered unemployable for mental or physical reasons.
(vii) A patient is not known to have abused alcohol or other drugs within the previous year.
(viii) A patient is not known to have engaged in any criminal activity within the previous year.
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Observations
Based on review of the policy and procedure manual and documentation provided to patients for orientation, the facility allows a 13 day take home supply of medication after 3 years of continuous treatment and does not address the need to seek an exception from the Department. The regulations do not permit a 13 day take-home supply unless via an exception.
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Plan of Correction
POC: The manual has had language added stating "the regulations do not permit a 13 day take-home supply unless via an exception". The DOH State regulations will be reviewed with the staff in weekly supervision, and weekly team meetings when the requests are presented. Pt will need to present documentation that explains the exception. These documents will accompany the exception request to the State.
Person(s) responsible: Program Director/Clinical Supervisor
Timeframe for completion: Immediate and on a weekly basis |
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 random review of the records of patients #1 and #20, the facility failed to document that the 13 day take-home exceptions were related to physical disabilities. Additionally, an exception request for 13 take-homes for patient #20 had been denied by the Department in April 2007, but the facility continued to provide the patient with 14 take-home doses at a time.
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Plan of Correction
POC: Exception requests will be resubmitted for #20 based on continued and serious medical need, and for patient #1 based on continued and serious medical need. As per the regulations, medical exceptions will be reviewed on an annual basis by the Medical Director. Chart reviews will be conducted by the Counselor and the Clinical Supervisor. Also,the medical documentation for #20 has been completed for continued 13-day exception with notation regarding on-going liver failure and the need for split dosing. New exception will be filed with the State with the accompanying medical documentation.
Person(s) responsible: Clinical Supervisor, Medical Director, and Primary Counselor
Timeframe for completion: within 7 days |
715.16(f) LICENSURE Take-home priveleges
(f) An exception granted under subsection (d) shall continue only for as long as the temporary disability or exceptional circumstance exists. When a patient is permanently disabled, that case shall be reviewed at least annually to determine whether the need for the exception still exists.
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Observations
Based on random review of patient record #1 and #20 who were given 13 day take-home doses, the facility failed to justify that the exception related to physical disability that required continued take-home status.
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Plan of Correction
POC: Exception requests will be resubmitted for #20 based on continued and serious medical need, and for patient #1 based on continued and serious medical need. Supporting medical documentation will be included in the exceptions. This documentation and exception request will be completed, within the 7 day timeframe, as indicated below.
Person(s) responsible: Clinical Supervisor, Medical Director, and Primary Counselor
Timeframe for completion: within 7 days |
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 random review of patient record #13 who was transferred to another NTP, the facility failed to document what materials were sent to the receiving program.
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Plan of Correction
POC: All fax sheets which list all required documentations for transfer to a continuum of drug and alcohol treatment will be saved, with the confirming transmittal sheet, in the patient's clinical chart. The Clinical Supervisor will check all transfer packets to ensure compliance.
Perons(s) responsible: Clinical Supservisor, Primary Counselor and Administrative Clinic Coordinator
Timeframe for completion: Immediate
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715.21(2) 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.
(2) A patient terminated involuntarily, except a patient who commits or threatens to commit acts of physical violence, shall be afforded the opportunity to receive detoxification of at least 7 days. The detoxification may take place at the facility or the patient may be referred to another narcotic treatment program or hospital licensed and approved by the Department for detoxification.
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Observations
Based on random review of three patient records terminated involuntarily, the facility failed to provide written notice to patient #10.
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Plan of Correction
POC: Clinical staff will receive a training, within 30 days, on providing written notice to any patient who is being terminated and the stated reasons for same. Also, patients will be reminded of their right to file a grievance for same. All termination letters must be signed by the Counselor and the Clinical Supervisor.
Person(s) responsible: Clinical Supervisor, Primary Counselor
Timeframe for completion: Within 30 days |
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 staff interviews, the facility failed to provide the documentation of the eight reported grievances filed in the past year, therefore, it cannot be determined if the program utilized the procedure they have developed.
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Plan of Correction
POC: All patient grievances, whether written by the patient or verbally reported to the Clinical Supervisor by the patient, will be documented in the Griveance book. It will be the Clinical Supervisors responsibility to support the patient during the process and to document all outcomes.
Person(s) responsible: Clinical Supervisor
Timeframe for completion: Immediate |
715.22(c) LICENSURE Patient grievance procedures
(c) Penalties may not be initiated prior to final resolution with the exception that penalties may be initiated against patients who have committed acts of physical violence or who have threatened to commit acts of physical violence in or around the narcotic treatment program premises.
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Observations
The facility failed document whether or not penalties were initiated prior to final resolution of an involuntary termination or grievance.
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Plan of Correction
POC: All Behavorial Contracts, Learning Experiences, etc. will be copied and attached to the Letter of Termination rather than being filed soley in another section of the clinical charts. Staff will receive supervision regarding this new protocol by the Clinical Supervisor within 30 days
Person(s) responsible: Clinical Supervisor and Primary Counselor
Timeframe for completion: Within 30 days |
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 random review of 20 patient records, the facility failed to conduct annual physical examinations that were completed or reviewed by the narcotic treatment physician in patient records #16 and #19.
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Plan of Correction
POC: Additional (contingency management)strategies are being designed by the Nurse Coordinator to ensure non-compliant patients meet their required annual physicals. Once developed, the plan will be implemented and tested to see if there is a higher rate of compliance.
Perons(s) responsible: Nurse Coordinator and Program Director
Timeframe for completion: Within 30 days |
715.23(b)(11) LICENSURE Patient records
(b) Each patient file shall include the following information:
(11) Counselor notes regarding patient progress and status.
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Observations
Based on random review of 20 patient records, the facility failed to provide documentation of patient progress and status. The notes contained generic information and had gaps of time without documentation when patients were being transferred between counselors.
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Plan of Correction
POC: Clinical staff will receive additional training and supervision regarding developing treatment specific treatment plans and progress notes, including documentation of intra-agency transfers of patients.
Clinical Supervisor will complete quarterly chart reviews to ensure compliance.
Person(s) responsible: Clinical Supervisor and Primary Counselor
Timeframe for completion: Within 30 days |
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 random review of 20 patient records, the facility failed to develop an evaluative assessment of the historical data obtained that included the counselor's clinical impressions. Instead, the psychosocial evaluations of the patient consisted primarily of the repetition of the history and statements reported by the patient; patient #15 and 17's evaluations were not completed within the facility's timeframe and patient #3 did not have an evaluation..
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Plan of Correction
POC: Clinical staff will receive additional training and clinical supervision regarding developing an analysis and assessment of the evaluative information obtained. Supervision will also include timeliness of PSH completion.
Person(s) responsible: Clinical Supervisor and Primary Counselor
Timeframe for completion: Within in 4 weeks |
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 random review of three patient records that required an annual evaluation, the facility failed to document an annual evaluation for patient #17.
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Plan of Correction
POC: Patient's Annual Evaluation has been completed. However, Clinical Supervisor will do a quarterly chart review to ensure all annual evaluation are completed.
Person(s) responsible: Clinical Supervisor and Primary Counselor
Timeframe for completion: Immediate |
715.23(d) 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.
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Observations
Based on random review of seven patient records, the facility failed to provide a treatment plan for patient #3, and the goals for #4, 15, 17 and 18 were not specific and generalized.
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Plan of Correction
POC; Patient #3 has been hospitalized for extensive periods (up to 7 weeks) of time due to serious psychiatric issues. Upon discharge and stability, treatment planning will commence with #3. For #4,15,17,18, the issue of more specific goals will be addressed in weekly supervision with the Clinical Supervisor.
Person(s) responsible: Clinical Supervisor and Primary Counselor
Timeframe for completion: Within 4 weeks |
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
The facility failed to comply with the conditions of 13 day take home exceptions that require quarterly callbacks to be done and documented. There was no call back documented for patient #20 in August 2007 and the counselor of record reported in a progress note that a call back was completed in November 2007. However, the counselor had also notified the patient a few weeks in advance that a call back would be conducted in a few weeks, defeating the purpose of an unscheduled required return to within 24-48 hours.
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Plan of Correction
POC: Call-back procedures and standards will be reviewed with the Primary Counselor and reinforced with all clinical staff during weekly supervision.
Perons(s) responsible: Clinical Supervisor
Timeframe for completion: Within 2 weeks |