INITIAL COMMENTS
|
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 July 28 & 29, 2009 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 was found not to be compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and a plan of correction is due on August 9, 2009.
|
Plan of Correction
|
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.
|
Observations
Based on the review of patient records, the facility failed to document prenatal support provided by the facility in one of four patient records reviewed.
The findings include:
Eighteen patient records were reviewed on July 25, 26 & 27, 2009. Four were required to have prenatal support documentation in the patient records. Patient record # 7 contained documentation that the patient was pregnant however there was no inclusion of the patient's pregnancy in the treatment plan.
|
Plan of Correction
A training was conducted with the staff empahsizing the importance of integrating all medical (pre-post natal) information, results of Post-Partum Depression Scales, within the clinical documentation (Progress Notes, Case Consultations, and Treatment Plans)for complete assessment and patient care.
The City of Philadelphia DBH provided addtional clinical documentation trainings on 7/28/09 & 8/25/09. An ACSW consultant was hired to provide weekly, documented supervision to the staff and to address the areas of non-compliance. We have hired a Clinical Director (9/2/09) which will provide consistent supervision and documentation auditing.
Timeframe for completion: Immediate
Person(s) responsible: Clinical director, Primary Counselors |
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.
|
Observations
Based on a review of 18 patient records, the facility failed to ensure the completion of random drug-screening urinalysis at least monthly in five of 18 records.
The findings include:
Eighteen records were reviewed July 28 - 30, 2009, all were required to contain documentation that pertained to drug-screen urinalysis results. The facility failed to document urinalysis results in five of eighteen records.
Patient record # 1 did not contain a urinalysis result for January 2009.
Patient record # 10 did not contain urinalysis results for April 2009.
Patient records # 14 did not contain urinalysis results for June 2009.
Patient record # 15 did not contain urinalysis results for June 2009.
|
Plan of Correction
A training regarding all citations, including 715.14 (a) was provided for all designated staff. Individual clinicl staff whose charts were cited received additional individual supervision with the Program Director. Each counselor cited now uses a tracking mechanisms for monthly UDS. The tracking mechanism will be reviewed in weekly, documented, supervisory sessions with the newly hired Clinical Director.
Timeframe for completion: Immediate
Person(s) responsible: Clinical Director and Counselor
|
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
|
Observations
Based on a review of patient records, the facility failed to provide documentation of the physician's bi-annual dose review in nine of nine records.
The findings include:
Eighteen records wer reviewed July 28 - 30, 2009. Nine were reviewed to contain documentation of the physician's bi-annual review. Patient records # 2, 3, 6, 10, 12, 13, 14, 15 17 failed to include documentation that identified that the physician had reviewed patient dosing levels at twice during the past year.
|
Plan of Correction
The methadone prescription form has been reformatted to include a "twice yearly dose review" section. Quarterly chart audits will be completed by the Clinical Director to ensure documented dose changes are completed and filed.
Timeframe for completion: Implementation will begin immediately and all charts will be reviewed for compliance within 30 days.
Person(s) responsible: Clinical Director, Medical Director, and Primary Counselor
|
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.
|
Observations
Based on a review of patient records, the facility failed to limit take-home privileges to only those patients who met the criteria in one of six patient records.
The findings include:
Based on a record review of 18 patient records, six were reviewed to determine patient responsibility in handling take-home medications. The facility failed to document an assessment of patient # 12's take-home privileges to determine if her current status should be maintained; the patient had take-home privileges but documentation in the patient record identified problems with clinic attendance and home environment. The facility failed to consider the eight point criteria when determining take-home privileges for this patient.
|
Plan of Correction
This citation was addressed and corrected with the patient meeting the
eight point criteria. The hiring of the Clinical Director will assist in closer cahrt auditing, close scrutiny of THB applications, and follow-up to ensure the patient continues to meet the criteria.
All THB's applications are being audited to ensure the criteria has been met and documented for THB.
Timeframe for completion: within 30 days
Person(s) responsible: Clinical Director and Primary Counselor |
715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
|
Observations
Based on a review of patient records, the facility failed to provide documentation that psychotherapy was provided to patients after four years of treatment in one of four patients reviewed.
The findings include:
Eighteen patient records were reviewed July 28 - 30, 2009, four were required to provide documentation of pychotherapy following four years of treatment. Patient # 10 has been in the facility's program since 2000; regulations require that she receive psychotherapy at least one hour every two months. Patient record # 10 did not contain documentation of psychotherapy between 2/17/09 and 5/19/09.
|
Plan of Correction
Each counselor has developed tracking grids/systems that list all required documents and timeframe for completion. The tracking system will be included in weekly supervision to ensure that all patients receive the required number of monthly clinical services.
Timeframe for completion: Immediate
Person(s) responsible: Clinical Director and Primary Counselor |
715.21 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.
|
Observations
Based on the review of patient records and the facility's policy and procedure and patient handbook, the facility failed to restrict the reasons for involuntary termination to those reasons allowed by regulation.
The findings include:
Eighteen patient records and facility policies were reviewed July 28 -30, 2009. Facility documentation specifies that patients may be involuntarily discharged for loitering. This facility policy exceeded the regulations regarding reasons to discharge a patient.
|
Plan of Correction
This policy is in response to the Federal mandate for programs to develop policies regarding a diversion control plan (DCP)and to demonstrate accountability for its patients and to the community.
The language will be modified and the issue of diversion will be addressed as a clinical issue. Loitering is a serious is and the policy states "may" not "will" be a reason for discharge and is addressed in terms of a behavorial consequence.
Timeframe for completion: within 30 days
Person (s) responsible: Program Director
|
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.
|
Observations
Based on a review of patient records and staff interviews, the facility failed to provide documentation that written notification was provided to patients who were to be involuntarily terminated in one of four patient records.
The findings include:
Eighteen patient records were reviewed July 28 -30, 2009, four were reviewed for involuntary discharge content. The facility failed to provide written notification to patient #3.
|
Plan of Correction
Staff received training regarding the inclusion of a termination letter for involuntary discharges. Also, staff were instructed to be consistent regarding the patient's discharge status. This patient was an administrative discharge and then chose to transfer. The documentation was not consistent with the new discharge status and, therefore, non-compliant.
Timeframe for completion: August 3, 2009
Person (s) responsible: Clinical Director and Primary Counselor |
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.
|
Observations
Based on a review of patient records, the facility failed to document the completion of a patient's annual physical examination in one of five records.
The findings include:
Eighteen patient records were reviewed July 28 -30, 2009, six were required to provide documentation of an annual physical examination. Patient record # 18 failed to provide documentation that an annual physical examination had been completed. The patient was admitted into treatment in March, 2007; there was no documentation of a physical examination for the years 2008 and 2009.
|
Plan of Correction
A new quarterly medical chart tracking system has been developed by the Nurse Coordinator that identifies any upcoming annual physical examinations that are due. The results of the tracking system will be communicated with the Management Team on a quarterly basis. Physical examination appointments will be scheduled by the Nurse Coordinator. Missed appointments will be discussed with the Clinical Director and addressed.
Timeframe for completion: within 30 days
Person(s) responsible: Nurse Coordinator and Clincal Director
|
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
|
Observations
Based on the review of patient records, the narcotic treatment program failed to document psychosocial evaluations in three of four patient records.
The findings include:
Eighteen patient records were reviewed on July 28 - 30, 2009. Psychosocial evaluations were required in four patient records. The narcotic treatment program did not include evaluations in all the required areas in the psychosocial evaluation in patient records # 7, 8 and 9. These patient records did not include a clinical evaluation of the patient problems/needs, assets/strengths, support systems, coping mechanism, factors that may inhibit treatment or counselor recommendations. The documentation of psychosocial evaluations in these patient records was primarily patient history with no clinical assessment provided by the counselor.
|
Plan of Correction
A training was conducted with the staff empahsizing the importance of the timely completion of all clinical documents. Each counselor has developed a tracking system to identify timeframe for completion. These tracking systems will be reviewed in weekly supervision by the Clinical Supervisor. Non-compliances will addressed in supervision and corrected.
Timeframe for completion: Immediate
Person(s) responsible: Clinical Director and Primary Counselor |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
|
Observations
Based on the review of patient records, the narcotic treatment program failed to document complete discharge summaries in one of four patient records.
The findings include:
Eighteen patient records were reviewed July 28 - 30, 2009. Discharge summaries were required in four patient records. The narcotic treatment program did not document discharge summaries that included all the required areas in patient record # 3 as the documentation did not address reason for discharge.
|
Plan of Correction
A documentation training was provided by the City of Philadelphia DBH on 8/25/09 with the next scheduled training 9/29/09. Also, this issue of non-compliance was reviewed with the clinical staff on 8/3/09.
Weekly clinical supervision and review of all discharge documents will be consistently provided with the hiring of the new Clinical Director.
Timeframe for completions (s): Immediate
Person(s) Responsible: Clinical Director and Primary Counselor |
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.
|
Observations
Based on a review of patient records, the facility failed to complete an annual evaluation in two of seven patient records.
The findings include:
Eighteen records were reviewed July 28 - 30, 2009, seven were required to have documentation regarding annual evaluations. Patient # 10 had an evaluation that was due June, 2009; there was no documentation of an annual evaluation in the patient's record. Patient # 18 had an annual evaluation completed 3/14/09; the evaluation failed to address a significant event in the patient's life that occurred in February 2009. This event effected the patient's legal status, treatment objectives and family but there was no documentation of the event in any category identified in the annual evaluation.
|
Plan of Correction
A overall clinical staff training was conducted on August 6, 2009 regarding documention. All staff have developed tracking grids/system to ensure timeliness of all documents. Individual training was provided the staff person identified in this non-compliance.
Quarterly chart audits and weekly supervision will help to identify and correct any missing future non-compliances.
Timeframe for completion: Immediate
Person(s) responsible: Clinical Director and Primary Counselor |
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.
|
Observations
Based on a review of patient records, facility documentation and staff interviews, the facility failed to submit an incident report, as required, to the Department.
The findings include:
A review of incident reports indicated an incident report was completed but not forwarded to the Department as required by regulation. A review with staff members identified that the incident report was required to be forwarded to the Department of Drug and Alcohol Program Licensure; the facility agreed the incident report should have been submitted to the Department as the incident had a potential for negative community reaction.
|
Plan of Correction
A check system will be used to ensure all parties receive the required incident reports in a timely manner. Incident reports will be faxed and proof of transmission attached to the incident report.
Timeframe for completion: Immediate
Person(s) responsible: Program Director |
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.
|
Observations
Based on a review of eighteen patient records, the facility failed to maintain a record of a patient exception in one of eighteen records.
The findings include:
Eighteen records were reviewed July 28 - 30, 2009. Patient # 14 was identified as having take-home privileges that required a specific exception. Further, a copy of this exception was to be maintained in the patient record. During the patient record review the documentation regarding the exception was not available. The facility is required to obtain an exception for thirteen day take-home privileges as well as maintain record of this at the facility.
|
Plan of Correction
An overall clinical staff training was conducted on August 6, 2009 regarding THB exceptions. All 13 THB requests are in the process of being audited to ensure the required documentation is appropriately completed and filed within the chart. Approved requests are required to be attached to the prescription.
Timeframe for completion: within 30 days
Person(s) responsible: Clinical Director, Primary Counselor |