INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use a narcotic agents, specifically methadone, in the provision of outpatient maintenance treatment for opioid dependence. This inspection was conducted on December 8-10, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Aldie Counseling Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on January 15, 2009. .
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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 a review of patient records, the facility failed to contact the previous facility for the patient's treatment history in two of two records reviewed.
Findings include:
Fourteen patient records were reviewed between December 8 and 10, 2008. Records # 1 and 5 were reviewed on December 9, 2008 and failed to contain documentation of contact for history from prior narcotic treatment programs.
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Plan of Correction
A standard letter will be formatted requesting discharge paperwork for any previously attended NTP. Orientation check list will now identify that releases were signed and a letter was sent to all previous NTP's. Quarterly chart review will ensure that the procedure has been followed. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on the review of patient records, the facility failed to demonstrate whether the patient was informed of the required information before an agent was administered in four of four records reviewed..
Findings include:
Fourteen patient records were reviewed between December 8-10, 2008. Four records were reviewed for informed consent on December 9, 2008. Patient records # 1, 2, 13 and 14 had signed consents, but the witness dated the patient's signature, making it impossible to determine if the patient was informed prior to the administration of the agent.
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Plan of Correction
Program Coordinator will provide training on the proper execution of releases with specific attention to witness signature and date. Specific nature and needs of the requirements of informed consents for pharmacotherapy will be highlighted during this training. Quarterly chart review will be completed to ensure the releases are being executed appropriately. |
715.21(1)(i-iv) 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.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
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Observations
Based on the review of patient records, the facility failed to restrict the reasons for involuntary termination to those allowed by regulation in one of four records reviewed.
Findings include:
Fourteen patient records were reviewed between December 8-10, 2008. Four records were reviewed for documentation of notification of intent to involuntarily terminate the patient. On December 9, 2008, patient record # 1 was reviewed and the documentation demonstrated the patient was being discharged for failure to bring in the copy of a prescription given by the primary care physician; this exceeded what is allowed by regulation.
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Plan of Correction
Aldie staff will be provided a copy of State Regulations and Aldie policy specific to involuntary termination as part of a specific training. Program Coordinator will provide a written copy of State Regulations regarding patient termination. Case Consults addressing involuntary termination will clearly identify only areas specific to these regulations and policies prior to the Program Coordinators signature. |
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 the review of patient records, the narcotic treatment program failed to document psychosocial evaluations in six of seven patient records.
The findings include:
Fourteen patient records were reviewed between December 8-10, 2008. Psychosocial evaluations were required in seven patient records. The facility failed to provide an evaluative assessment of the patient history obtained by clinical staff that included the counselor's clinical analysis of the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, patient's attitude toward treatment and overall impressions. Instead, the psychosocial evaluations of the patient consisted primarily of the repetition of the history and statements reported by the patient in 6 of 7 records reviewed for content, specifically patient records # 1, 2, 5, 6, 7 and 13.
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Plan of Correction
Program Coordinator will provide additional training on how to interpret factual information into a clinical analysis of the patients problems, needs, support systems, negative factors, attitute toward treatment and overall impressions. The clinical assessment will be reviewed by the Program Coordinator for adherence of a more clinical analysis rather than a historical documentation of clients' presentation prior to signature. Peer chart review will be conducted on a monthly basis. A quarterly chart review will be conducted by the Program Coordinator to assure adherence to standards. Compliance Officer will similarly randomly review charts for adherence to standards. |
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 narcotic treatment program failed to document annual evaluations in one of two patient records reviewed.
The findings include:
Fourteen patient records were reviewed between December 8-10, 2008. On December 10, 2008, two patient records were reviewed for annual evaluations. One of the two was not documented in the record, specifically record # 8. The annual evaluation was due by June 30, 2008.
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Plan of Correction
Every patient will receive an annual evaluation by thier counselor. Each clinician will now retain a spreadsheet/checklist which will track patient anniversary date, annual evaluation date and other key benchmarks. This spreadsheet and client chart will be reviewed by the Program Coordinator and Clinician in individual supervision on a monthly basis to insure compliance to this standard. |
715.23(d)(1) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(1) The treatment plan shall identify the behavioral tasks a patient shall perform to complete each short-term goal.
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Observations
Based on the review of patient records, the narcotic treatment program failed to document behavioral tasks for the patient to perform in three of four patient records.
The findings include:
Fourteen patient records were reviewed between December 8-10, 2008. Four records were reviewed for treatment plan documentation. Records # 1, 2 and 13 did not contain action steps for the patient to perform to meet their goals and objectives developed in the treatment plan.
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Plan of Correction
Further training will be provided to all clinicians by the Program Coordinator on writing treatment plans that contain action steps for the patient to perform to meet goals and objectives identified in the Treatment Plan. Treatment Plans will be reviewed by the Program Coordinator prior to signature to insure adherence. The Compliance Officer will randomly monitor charts for adherence to this standard. |
715.23(d)(2) 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.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Based on the review of patient records, the narcotic treatment program failed to document complete treatment plan updates in five of six patient records.
The findings include:
Fourteen patient records were reviewed between December 8-10, 2008. Treatment plan updates were required in six patient records. The narcotic treatment program did not document in the treatment plan updates the patient's progress in relationship to the stated goals in patient records #1, 4, 6, 7 and 12.
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Plan of Correction
In conjunction with Treatment Plan training to be conducted for standard M271 staff will receive training on how to reflect progress in response to stated goals. Treatment Plan updates, moving forward, will clearly identify the clients progress in relationship to the stated goals in the previous Treatment Plan. The Program Coordinator will review Treatment Plans prior to signature to insure that the protocol is maintained. The Compliance Officer will randomly review charts to insure compliance to these standards. |