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 and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on December 20-22, 2010 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 January 21, 2011.
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Plan of Correction
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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 the review of patient records, the facility failed to contact the previous narcotic treatment facility for the patient's treatment history in five of five patient records reviewed.
The findings include:
Twenty eight patient records were reviewed December 20-22, 2010. Five patient records required contacting the prior narcotic treatment facility for the previous treatment history the patient's reported to have received.
Patient records # 1, 3, 8, 23 and 28 contained documentation the patients had received narcotic treatment services previously at other narcotic treatment programs. None of the five patient records reviewed contained documentation of any attempt to obtain the patients' prior treatment history from the previously attended narcotic treatment facilities.
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Plan of Correction
Effective immediately, The Program Director will provide training to the Intake Specialist regarding contacting previous facility(s) for consumers who have a treatment history.
The Clinical Supervisor will review compliance with DOH regulation by completing chart audits on new admissions.
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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 a review of patient records, the facility failed to maintain patient confidentiality in accordance with 42 CFR 2.22 and 4 PA code 255.5 in two of fourteen patient records.
The findings include:
Twenty-eight patient records were reviewed December 20-22, 2010. Fourteen patient records were reviewed specifically for compliance with 42 CFR 2.22 and 4 PA Code 255.5. Two patient records contained documentation of information being released to outside entities without a signed consent to release any information.
Patient record # 9 contained documentation that a letter was sent out August 8, 2010 acknowledging the patient had been admitted. There was no signed consent to allow this information to be released. In addition, a letter dated November 19, 2010 was documented in the patient record, but there was no identification as to whom it was written to ascertain if there was a corresponding signed release of information to go with it.
Patient record # contained documentation of multiple phone calls being made to three other narcotic treatment programs during the month of November 2010, in an attempt to transfer the patient. There were no signed consents to release information to any of the three programs that were contacted. The patient was transferred to a fourth narcotic treatment program November 23, 2010 and there was no signed consent to release information to that program.
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Plan of Correction
Training on Confidentiality and Release of Information will be provided by 3/30/11 for clinical staff. Adherence to the training will be monitored by the Clinical Supervisor in ongoing supervision and chart audits. |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on the review of patient records, the facility failed to transfer the required patient files in three of four patient records.
The findings include:
Twenty eight patient records were reviewed December 20-22, 2010. Four patient records required the facility transfer specific patient files to the receiving narcotic treatment program as part of the transfer process. Three patient records did not transfer the specified documentation
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Patient # 13 was discharged as a transfer to another narcotic treatment facility November 11, 2010. There was no documentation of the required patient documentation being transferred to the receiving facility.
Patient # 17 was discharged as a transfer to another narcotic treatment facility December 1, 2010. There was no documentation that the required patient documentation was transferred to the receiving facility.
Patient # 27 was discharged as a transfer to another narcotic treatment facility October 20, 2010. There was no documentation that the required patient documentation was transferred to the receiving facility.
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Plan of Correction
Training on Documentation/Transfer of Client Treatment Services will be provided to all clinical Staff by 2/28/11. The Clinical Supervisor will ensure compliance by completing reviews in ongoing supervision. |
715.20(4) 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.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records and staff interviews, the facility failed to document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program in ten of eleven patient records.
The findings include:
Twenty-eight patient records were reviewed on December 20-22, 2010. Eleven patients were transferred into treatment from another narcotic treatment program. The facility failed to document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient in records # 1, 3, 6, 8, 9, 13, 14, 17, 23 and 24.
Patient # 1 was transferred from a narcotic treatment program and admitted into treatment on October 7, 2010. There was no documentation that the facility notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient.
Patient # 3 was transferred from a narcotic treatment program and admitted into treatment on August 8, 2010. There was no documentation that the facility notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient.
Patient # 6 was transferred from a narcotic treatment program and admitted into treatment on August 9, 2010. There was no documentation that the facility notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient.
Patient # 8 was transferred from a narcotic treatment program and admitted into treatment on August 12, 2010. There was no documentation that the facility notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient.
Patient # 9 was transferred from a narcotic treatment program and admitted into treatment on July 15, 2010. There was no documentation that the facility notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient.
Patient # 13 was transferred from a narcotic treatment program and admitted into treatment on July 15, 2010. There was no documentation that the facility notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient.
Patient # 14 was transferred from a narcotic treatment program and admitted into treatment on August 8, 2010. There was no documentation that the facility notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient.
Patient # 17 was transferred from a narcotic treatment program and admitted into treatment on August 5, 2010. There was no documentation that the facility notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient.
Patient # 23 was transferred from a narcotic treatment program and admitted into treatment on October 19, 2010. There was no documentation that the facility notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient.
Patient # 24 was transferred from a narcotic treatment program and admitted into treatment on August 3, 2010. There was no documentation that the facility notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient.
An interview with the facility director was conducted on December 21 and 22, 2010 regarding the lack of documentation of the notice to the transferring facility. The facility director acknowledged that the required documentation had not been provided.
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Plan of Correction
The Intake Specialist will provide notification to the referring treatment facility of patient's admission and confirmation of first dose. An acknowledgment letter will be utilized, a fax transmittal of document sent will be attached and all documentation will be placed in patient's record. The Clinical Supervisor will ensure that this documentation is completed with the Intake Chart Audit tool utilized on all new admissions. |
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 in ten of seventeen patient records.
The findings include:
Twenty eight patient records were reviewed on December 20-22, 2010. Seventeen patient records were reviewed for case consultations. Patient records # 4, 5, 12, 13, 17, 18, 19, 20, 22 and 27.
Case consultations are required at least quarterly for the first year of treatment and at least annually thereafter.
Patient # 4 was admitted May 9, 2007. The last case consultation was done May 9, 2009. Another case consultation was to have been completed by May 2010.
Patient # 5 was admitted June 2, 2008 and was discharged August 30, 2010. There were no case consultations documented in the patient's record.
Patient # 12 was admitted June 19, 2007. There were no case consultations documented in the patient record between June 18, 2008 and December 20, 2010.
Patient # 13 was admitted July 15, 2010. A case consultation was due by October 15, 2010. It was not completed until November 11, 2010.
Patient # 17 was admitted August 5, 2010. The patient was discharged for non-compliance December 1, 2010. At least one case consultation was to have been completed.
Patient # 18 was admitted September 2, 2009. There was only one case consultation completed ( September 14, 2010). Patient # 19 was admitted August 14, 2010. There were no case consultations documented between August 14, 2008 and August 13, 2010.
Patient # 20 was admitted April 6, 2009. The last case consultation was done August 2, 2009. The patient is still active in treatment.
Patient # 22 was admitted September 7, 2010. There were no case consultations completed since the patient was admitted.
Patient # 27 was admitted October 29, 2008. The patient was discharged September 28, 2010. The last case consultation was done June 22, 2009. Another case consultation was to have been completed by June 2010.
A discussion with the facility director was conducted on December 21 and 22, 2010 regarding the lack of documented case consultations. The facility director acknowledged that case consultations had not been completed as required, but a new format had been developed and the staff are currently being trained to address this issue.
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Plan of Correction
The Clinical Supervisor will provide supervision to all Clinicians regarding timely submission and documentation of case consults.The Clinical Supervisor will also maintain a Documentation Tracker to support monitoring of clinical documentation to ensure complaince of timely submission. This will be monitored in scheduled supervision by the Clinical Supervisor. |
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 a review of patient records and discussion with facility staff, the facility failed to complete an aftercare plan in two of two patient records that were discharged as completed treatment.
The findings include:
Twenty eight patient records were reviewed December 20-22, 2010. Two patient records required a completed aftercare plan prior to discharge.
Patient # 15 was admitted November 30, 2007. The patient was discharged September 22, 2010 as completed treatment and therefore required an aftercare plan to have been established with the patient prior to discharge. There was no documentation this had been completed or that the patient had refused.
Patient # 16 was admitted July 17, 2009. The patient was discharged as of December 17, 2010 as having completed treatment and therefore required an aftercare plan to have been established with the patient prior to discharge. There was no documentation this had been completed or that the patient had refused.
An interview with the facility director and clinical supervisor confirmed there were no aftercare plans in the two specified records.
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Plan of Correction
Training will be provided to all clinical staff regarding Aftercare Planning by 2/15/11. The Clinical Supervisor will monitor compliance in ongoing supervision. |
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 four of nine patient records reviewed.
The findings included:
Twenty eight patient records were reviewed on December 20-22, 2010. Nine patient records were reviewed for annual evaluations.
Patient # 5 was admitted June 2, 2008 and was discharged August 30, 2010. There were no annual evaluations documented in the patient's record.
Patient # 12 was admitted June 19, 2007. There was no annual evaluation in the patient file until December 20, 2010.
Patient # 20 was admitted April 6, 2009. There was no annual evaluation in the record, due April 2010.
Patient # 27 was admitted October 29, 2008. There were no annual evaluations documented in the patient record.
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Plan of Correction
Training will be provided to the clinical staff regarding Annual Evaluations by 2/28/11. The Clinical Supervisor will monitor compliance in ongoing supervision. |