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 August 6, 2013 to August 8, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Kensington Hospital Outpatient Treatment Program 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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715.9(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 document the basis for determining current and one year history of dependency in three of three records reviewed
The findings include:
Eleven patient records were reviewed August 6 to 8, 2013. Three patient records were reviewed for physician documentation of evidence of current dependency of at least one year, # 8, 9 and 10.
Patient record # 8 documented an admission date of June 28, 2013. The only documentation by the physician for determining current dependency was the patient's statement. The determination for at least one year history of dependence was not documented in the patient record. This documentation was dated July 1, 2013, after the patient's admission and first dose of medication.
Patient record # 9 documented an admission date of May 17, 2013. The only documentation by the physician for determining current dependency was the patient's statement. The determination for at least one year history of dependence was not documented in the patient record. This documentation was dated May 23, 2013, after the patient's admission and first dose of medication.
Patient record # 10 documented an admission date of July 24, 2013. The only documentation by the physician for determining current dependency was the patient's statement. The determination for at least one year history of dependence was the patient's statement and a positive urine drug screen. This documentation was dated June 20, 2013. The urine drug screen on 7/24/2013 was negative for all substances.
The findings were reviewed with the Project Director, Medical Director and Facility Director and were not disputed.
This is a repeat deficiency from the monitoring visit on 2/28/2013 and 8/8/2012.
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Plan of Correction
Prior to admission to the Program, the client will sign a consent for Release of Information detailing previous treatment. At a meeting with the Narcotic Treatment Physician held on 8/30/13, he was updated to use the client's statement and results of physical assessment to determine eligibility for admission to Program, as well as for the initial dose of methadone. The Physician will then document all determining factors on the medical record. The Director of Behavioral Health Services will review all newly admitted client charts on a bi-weekly basis to assure continued compliance. |
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 one of one patient record reviewed.
The findings include:
Eleven patient records were reviewed August 6 to 8, 2013. One patient record required contacting the prior narcotic treatment facility for the previous treatment history the patient reported to have received.
Patient record # 9 documented an admission date of May 17, 2013. The record contained documentation the patient had received narcotic treatment services previously at another narcotic treatment program. There was no documentation the facility made any attempt to contact the previous treatment provider for the patient's prior treatment history.
The findings were reviewed with the Project Director, Medical Director and Facility Director and were not disputed.
This is a repeat deficiency from the monitoring visit on 2/28/2013 and 8/8/2012.
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Plan of Correction
In a staff meeting held on 8/28/13, it was decided that for every new client to the program, the Intake Worker will obtain a signed consent form for Release of Information to confirm the one year dependency protocol that must be satisfied before a client is admitted to the Program.
The Director of Behavioral Health Servies will be responsible for the continued complianced by conducting bi-weekly chart reviews for new clients. |
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 and administrative documentation, the facility failed to adhere to Federal confidentiality requirements 42 CFR 2.22, 4 Pa Code 255.5 and 709.28 in five of five patient records reviewed.
The findings include:
Eleven patient records were reviewed August 6 to 8, 2013. Five patient records were reviewed specifically for confidentiality compliance.
4 Pa. Code 255.5 (b) states:
(b) Restrictions. Information released to judges, probation or parole officers,
insurance company health or hospital plan or governmental officials, under subsection
(a)(1), (2), (4), (7) and (8), is for the purpose of determining the advisability
of continuing the client with the assigned project and shall be restricted to
the following:
(1) Whether the client is or is not in treatment.
(2) The prognosis of the client.
(3) The nature of the project.
(4) A brief description of the progress of the client.
(5) A short statement as to whether the client has relapsed into drug, or
alcohol abuse and the frequency of such relapse.
Patient record # 1 contained a consent to release information to a funding source that was directed to member services and included information regarding payment, utilization review, quality assurance. The purpose listed was to monitor ongoing treatment/continuing care support services.
Patient record # 5 was sent to a funding source for review per the Facility Director. Per regulation 42 CFR Subpart D 2.53 Audit and Evaluation Activities permits a funding source to review patient records onsite. The regulation specifically states under (a) Records not copied or removed (ii) permits a third party payer to review records on program premises.
Patient records # 8, 9 and 10 each contained a consent to release information to a transportation provider with the only information checked to be released was the nature of the program. The patient's presence in treatment including the admission and discharge dates were required by the receiver of the information.
A review of the documentation of grievances provided on August 6, 2013, by the Facility Director included letters sent to the funding source that included dosing history and urine drug screen results.
The findings were reviewed with the Project Director, Medical Director and Facility Director and were not disputed.
This is a repeat deficiency from the monitoring visit on 2/28/2013, 8/8/2012 and 10/20/2011.
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Plan of Correction
A staff meeting was held on 8/27/13 to review all standards. The Director of Behavioral Health Services will be responsible for responding to the payor for all patient grievances. All disclosed information will be limited by the five (5) areas that information can be discussed.
The Performance Improvement Coordinator will monitor the responses to the client grevances (as needed) to assure continued compliance. |
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 the review of patient records, the facility failed to complete an initial intake physical examination in two of three records, as required.
The findings include:
Eleven patient records were reviewed August 6 to 8, 2013. Three patient records were reviewed for initial intake physical examinations.
Patient record # 8 documented an admission date of June 28, 2013. The initial intake physical examination was dated July 1, 2013, after the patient's admission and first dose of medication.
Patient record # 9 documented an admission date of May 17, 2013. The initial intake physical examination was dated May 23, 2013, after the patient's admission and first dose of medication. The physical examination was documented with different ink. The initial date of May 17, 2013 was documented with the same ink as the vital signs. The remaining content, the physician's signature and date were documented with different ink.
Patient record # 10 documented an admission date of July 24, 2013. The initial intake physical examination was dated June 20, 2013. The general appearance was documented as vital signs. The patient was admitted and received the first dose of medication over one month after the physical assessment with no further documentation of review.
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Plan of Correction
The Intake protocol has been reviewed and revised so that the Narcotics Treatment Physician will complete the physical examination prior to the PIR being admitted to the MAT program. This will enable the Medical Director to complete all of the paperwork and assessments before the client is even admitted to treatment in the MAT. This protocol was revised on 8-29-13 in a staff meeting that included the Director of Behavioral Health, the Narcotics Treatment physician, and the Intake Coordinator to insure compliance with the new protocol. |
715.16(a)(2) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(2) The narcotic treatment physician shall make this determination after consultations with staff involved in the patient's care.
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Observations
Based on the review of patient records, the facility failed to ensure the physician made take home determinations after consulting with the staff involved in the patient's care in one of one patient record reviewed.
The findings include:
Eleven patient records were reviewed August 6 to 8, 2013. One patient record was reviewed for take home medication procedures.
Patient record # 7 documented one take home bottle was granted on June 10, 2013. The record contained no documentation of a consultation by the physician with the staff involved in the patient's treatment.
The findings were reviewed with the Project Director, Medical Director and Facility Director and were not disputed.
This is a repeat deficiency from the monitoring visit on 2/28/2013.
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Plan of Correction
At a staff meeting on 8/21/13, a discussion regarding the eligibility of a client for approved take-home bottles (THB). Each request for THB will be reviewed by the Narcotic Treatment Physician and the Counslor. At this time, all paper work and physician statements will be completed prior to the client receiving a THB.
The Director of Behavioral Health Services will assure continued compliance by reviewing the updated client take home list on a bi-weekly basis. |
715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
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Observations
Based on the review of patient records, the facility failed to ensure the physician documented the rationale for granting take home privileges in one of one patient record reviewed.
The findings include:
Eleven patient records were reviewed August 6 to 8, 2013. One patient record was reviewed for take home medication procedures.
Patient record # 7 documented one take home bottle was granted on June 10, 2013. The record documentation of June 10. 2013, noted group attendance and clean urine since admission, however, did not identify the rationale of the physician in regards to these areas.
The findings were reviewed with the Project Director, Medical Director and Facility Director and were not disputed.
This is a repeat deficiency from the monitoring visit on 2/28/2013.
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Plan of Correction
At a staff meeting on 8/21/13, a discussion regarding the eligibility of a client for approved take-home bottles (THB)was discussed.
Each request for THB will be
1. reviewed by the Narcotic Treatment Physician and the Counselor. After it is determined that the pt will or will not receive a THB, or additional THB. A brief note shall be entered in the pt's chart.
2. This note shall document the rationale for the THB and include at least 4 of the accepted 8 points as reasons for giving THBs and this brief note shall be signed by both the NTP and the counselor indicating that they both were involved in the decision.
3. Also, all paper work and physician statements will be completed prior to the client receiving a THB and the order will be reviewed by the dispensing nurse.
4. Finally, the Director of Behavioral Health Services will assure continued compliance by reviewing the patients' charts who receive THB. This review will be done n a quarterly basis.
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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 a review of patient records, the facility failed to ensure the physician considered the eight points required for granting take home privileges in one of one patient record reviewed.
The findings include:
Eleven patient records were reviewed August 6 to 8, 2013. One patient record was reviewed for take home medication procedures and the consideration by the physician of the criteria required for granting them.
Patient record # 7 documented one take home bottle was granted on June 10, 2013. The record contained no documentation the eight points were considered in determining the patient was responsible in handling narcotic drugs prior to the granting of the take home bottle.
The findings were reviewed with the Project Director, Medical Director and Facility Director and were not disputed.
This is a repeat deficiency from the monitoring visit on 2/28/2013.
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Plan of Correction
At a staff meeting on 8/21/13, a discussion regarding the eligibility of a client for approved take-home bottles (THB)was discussed.
Each request for THB will be:
1. reviewed by the Narcotic Treatment Physician and the Counselor. After it is determined that the pt will or will not receive a THB, or additional THB. A brief note shall be entered in the pt's chart.
2. This note shall document the rationale for the THB and include at least 4 of the accepted 8 points as reasons for giving THBs and be signed by both the NTP and the counselor indicating that they both were involved in the decision.
3. Also, all paper work and physician statements will be completed prior to the client receiving a THB and the order will be reviewed by the dispensing nurse.
4. Finally, the Director of Behavioral Health Services will assure continued compliance by revieiwng the patients' charts who receive THB. This review will be done on a quarterly basis. |
715.16(c)(1)(i-iv) 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:
(1) A narcotic treatment program may permit a patient to reduce attendance at the narcotic treatment program for observation to three times weekly and receive no more than a 2-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 months.
(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.
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Observations
Based on a review of patient records, the facility failed to include documentation in the patient record of the clinical judgment for reduced attendance in one of one patient record reviewed.
The findings include:
Eleven patient records were reviewed August 6 to 8, 2013. One patient record was reviewed for documentation of the clinical judgment of reduced attendance at the narcotic treatment program.
Patient record # 7 documented reduced attendance was granted on June 10, 2013. The record contained no documentation of the clinical judgment of the physician.
The findings were reviewed with the Project Director, Medical Director and Facility Director and were not disputed.
This is a repeat deficiency from the monitoring visit on 2/28/2013.
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Plan of Correction
At a meeting of 8/16/13, it was decided that the Narcotic Treatment Physiccan will justify the reduction of a client's attendance at the program. This will be necessary when a client is granted a second or an additional take home bottle. To assure continued compliance, the Director of Behavioral Health Services will review the designated medical charts for three (3) months to assure future compliance. |
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, the facility failed to ensure the physician completed a written dosage change in three of three records reviewed
The findings include:
Eleven patient records were reviewed August 6 to 8, 2013. Three patient records were reviewed for the patient's induction into methadone maintenance, # 8, 9 and 10.
Patient record # 8 documented an admission date of June 28, 2013. The record documented a physician order on June 28, 2013, of 30 mg per day with an increase of the patient's dose to 40 mg per day on Saturday (June 29, 2013). The Clinical Opiate Withdrawal Scale (COWS) identified a score of 3. A score of 5 to 10 on the COWS was identified as mild.
Patient record # 9 documented an admission date of May 17, 2013. The record documented a physician order on May 17, 2013, of 30 mg per day with an increase of the patient's dose to 40 mg per day tomorrow. The Clinical Opiate Withdrawal Scale identified a score of 3. A score of 5 to 10 on the COWS was identified as mild.
Patient record # 10 documented an admission date of July 24, 2013. The record documented a physician order on July 24, 2013, of 30 mg per day with an increase of the patient's dose to 40 mg per day on Thursday (July 25, 2013). The Clinical Opiate Withdrawal Scale identified a score of 1. A score of 5 to 10 on the COWS was identified as mild. The record documented a physician order on July 26, 2013, to increase the patient's dose to 50 mg and increase to 60 mg on Saturday (July 27, 2013). Another physician order documented on July 29, 2013, stated to increase the patient's dose by 10 mg to 70 mg and increase again tomorrow to 75 mg.
The findings were reviewed with the Project Director, Medical Director and Facility Director and were not disputed.
This issue of standing orders was addressed September 4, 2007 when the DEPARTMENT OF HEALTH & HUMAN SERVICES Substance Abuse and Mental Health Services Administration addressed all narcotic treatment facilities, stating in part the following:
"In determining the initial dose for each individual patient, the physician should consider factors such as body weight, size, other substance use and abuse, diet, co-occurring disorders (check for prescribed SSRI's, benzodiazepines, HIV medications, anti-seizure medication, etc.) and medical diseases, genetic factors, and tolerance. The drug labeling states that 'methadone's pharmacokinetic properties, coupled with high inter-patient variability in its absorption, metabolism, and relative analgesic potency, necessitate a cautious and highly individualized approach to prescribing.' Even though the Treatment Improvement Protocol (TIP #43) and drug labeling state that a typical first dose of methadone for a patient actively abusing opioids is 20 to 30 milligrams, some patients may require a much lower dose. According to 42 CFR 8.12 (h) (3) (ii), "...the initial dose of methadone shall not exceed 30 milligrams and the total dose for the first day shall not exceed 40 milligrams.. .." (emphasis added). The initial methadone dose should be appropriate for the individual patient, with the
maximum initial dose being 30 mg. Clearly, a 30-mg dose should not be the initial dose
for all patients.
Of note, there has been a rapid increase in the abuse of the opioid-type pain relieving
medications. Typically, hydrocodone and oxycodone are the drugs of choice, and the
resulting addiction is treated by the OTP's (Opiate Treatment Programs). These are short-acting opioids with a half-life of 2 to 4 hours. However, methadone has an elimination half-life that can vary from 8 to 59 hours depending on the individual being treated. Thus, methadone induction must be approached cautiously.
Because methadone overdose deaths have occurred in early treatment due to the drug's
cumulative effects of the first several days, it is also important to be cautious when
adjusting the dose. According to the drug labeling, the peak respiratory depressant
effects of methadone typically occur later and persist longer than its peak analgesic effects, which can contribute to cases of iatrogenic overdose, particularly during
treatment initiation and dose titration. With repeated dosing, 'methadone may be
retained in the liver and released slowly, prolonging the duration of action despite low
plasma concentrations.' The drug labeling also states that 'steady-state concentrations
are not usually attained until 3 to 5 days of dosing,' and that doses 'will "hold" for a
longer period of time as tissue stores of methadone accumulate.' Therefore, patients
should be closely monitored during the induction phase, and the increase in dose should
be under the close supervision of a physician as stated in 42 CFR 8.12 (h)(4), 'Dosing
and administration decisions shall be made by a program physician familiar with the most
up-to-date product labeling' ."
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Plan of Correction
At a staff meeting that was held on 8-29-13 and included the Director of Behavioral Health Services, the Narcotics Physician, and the Intake personnel, it was decided that no client will be admitted to MAT until certain protocol are met. After the initial dose of medication is dispensed in an induction stage, the PIR will return for a med check with the Medication physician the next day to continue the induction process. All necessary paperwork will be in place so that the physician has the data to determine the initial dose, and no standing order will be used for the next steps in Induction. This will be monitored by the Director as well as the Performance Review Personnel. The process will be examined on a weekly basis by the PRP with any new clients in the MAT. |
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 an annual physical with a re-evaluation by the narcotic treatment physician in two of three patient records reviewed.
The findings include:
Eleven patient records were reviewed August 6 to 8, 2013. Three patient records were reviewed for an annual physical with re-evaluation.
Patient record # 3 documented an admission date of May 25, 2012 and a discharge date of August 6, 2013. The annual physical exam was last documented on June 1, 2012, with no further documentation. An annual physical exam was due by May 25, 2013.
Patient record # 5 documented an admission date of June 3, 2008 and a discharge date of July 20, 2013. The annual physical exam was last documented on October 22, 2012, with no further documentation. An annual physical exam was due by June 3, 2013.
This is a repeat deficiency from the monitoring visit on 2/28/2013.
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Plan of Correction
A meeting was held on 8/22/13 with Clinical staff members (Narcotic Treatment Physician, Director of Behavioral Health Services, Counselors)to discuss missing annual assessments from the Narcotic Treatment Physician. The Admission Intake Worker will be responsible to re-schedule all missed annual assessments. The physician will complete the scheduled medical appointments for clients on their anniversary date and twice more for medication checks. The Director of Behavioral Health Services will be responsible to assure continue compliance by conducting random monthly chart reviews focusing on the missed annual assessments. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on the review of patient records, the facility failed to document a discharge summary with all of the required information in five of five patient records.
The findings include:
Eleven patient records were reviewed August 6 to 8, 2013. Five patient records were reviewed for discharge summary documentation, # 2, 3, 4, 5 and 6.
Patient record # 2 documented an admission date of January 10, 2005 and a discharge date of May 28, 2013. Discharge summaries are to be completed within 7 days of discharge. The discharge summary was documented on June 7, 2013, eleven days after discharge. The reason for admission was documented as opiate dependence. As this is a narcotic treatment program that only accepts opiate dependent patients, this reason is not individualized to the patient.
Patient record # 3 documented an admission date of May 25, 2012 and a discharge date of August 6, 2013. The reason for admission was documented as opiate dependence. As this is a narcotic treatment program that only accepts opiate dependent patients, this reason is not individualized to the patient.
Patient record # 4 documented an admission date of November 16, 2012 and a discharge date of May 14, 2013. The patient condition upon discharge was not documented.
Patient record # 5 documented an admission date of June 3, 2008 and a discharge date of July 20, 2013. Discharge summaries are to be completed within 7 days of discharge. The discharge summary was documented on August 1, 2013, twelve days after discharge. The discharge summary did not document a reason for entering treatment, the patient's response to the treatment process, services offered during the treatment stay and the condition of the patient upon discharge.
Patient record # 6 documented an admission date of March 26, 2013, and a discharge date of June 21, 2013. The reason for admission was documented as opiate dependence. As this is a narcotic treatment program that only accepts opiate dependent patients, this reason is not individualized to the patient.
The findings were reviewed with the Project Director, Medical Director and Facility Director and were not disputed.
This is a repeat deficiency from the monitoring visit on 2/28/2013.
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Plan of Correction
On 8/30/13 a staff meeting was held with the Narcotic Treatment Physicians, Director of Behavioral Health Services and the Counselors to finalize plans for discharge records. It was decided that the Summary will be completed within 7 days of discharge. The necessary details such as the Recovery Plan, referrals to other agencies, etc. will be included in the Discharge Summary.
The Director of Behavioral Health Services will be responsible to assure continued compliance by conducting a discharge summary review each month. |
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 document annual evaluations in accordance in two of two patient records reviewed.
The findings include:
Eleven patient records were reviewed August 6 to 8, 2013. Two patient records were reviewed for annual clinical review documentation, # 1 and 5.
Patient record # 1 documented an admission date of February 16, 2012. An annual clinical evaluation was documented on February 19, 2013. The evaluation contained one word answers, yes/no and lacked history review of the year.
Patient record # 5 documented an admission date of June 3, 2008 and a discharge date of July 20, 2013. The annual clinical evaluation was last documented on June 3, 2012, with no further documentation. An annual clinical evaluation for June 2013 was not documented in the patient record at the time of the inspection.
The findings were reviewed with the Facility Director and were not disputed.
This is a repeat deficiency from the monitoring visit on 2/28/2013.
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Plan of Correction
A staff training was held on 9/4/13 to update counselors on the appropriate way to complete responses to provided questions in an annual assessment. The Counselors will use more than simply "Yes" and "No" answers when completing this form. The date for completion of the annual assessment will be as close to the original date of admission as possible. The Director of Behavioral Health Services will assure continued compliance by reviewing each chart due for this process prior to affixing his signature to the assessment. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on a review of administrative documentation, the facility failed to provide documentation of incident reports involving patient distribution of illicit substances near the facility to the Department.
The findings include:
During the onsite methadone monitoring review, the facility provided documentation of incident reports that identified patient distribution of illicit substances near the facility. The facility failed to provide the Department with a written report that provided an account of the patient distribution of illicit substances with the potential for negative community reaction.
The findings were reviewed with the Project Director, Medical Director and Facility Director and were not disputed.
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Plan of Correction
The Director of Behavioral Health Services will forward any Unusual Incident Reports to the Department of Drug & Alchool Program. Some Unusual Incidents include: client deaths, client acts of violence and clients selling drugs in and around the treatment facility. The Performance Improvement Coordinator will assure continued compliance by reviewing all reported Unusual Incidents that occur. |