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 October 14, 2009 and November 16-17, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Knighton Hospital Outpatient Treatment 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 December 24, 2009.
|
Plan of Correction
|
715.5(1-5) STANDARD Patient capacity
The Department may increase or decrease the number of patients a narcotic treatment program may treat. The Department may raise the patient capacity, upon the written request of the narcotic treatment program, based upon the Department 's review of the narcotic treatment program. The factors the Department will consider include:
(1) Safety. Considerations include dispensing time, internal patient flow and external traffic patterns.
(2) Physical facility. Considerations include the number and size of counseling offices, waiting areas, restrooms, and dispensing and nursing windows.
(3) Staff size and composition. Considerations include the number of narcotic treatment physicians, dispensing and counseling staff.
(4) Ability to provide required services. Considerations include compliance with licensing and narcotic treatment program regulations as determined during licensing, monitoring and special visits to the narcotic treatment program.
(5) Availability and accessibility of service. Considerations include the location of the narcotic treatment program and the hours of operation.
|
Observations
Based on administrative documentation and staff interviews, the facility had failed to maintain a census at or below the licensed capacity.
The findings include:
The administrative documentation that included the daily census was reviewed on November 16 and 17, 2009. The facility is licensed for up to 160 methadone maintenance patients. The census at the time of the survey was 165 active patients. A discussion was held with the facility director on November 16, 2009 and she stated she was using the licensed drug free spots, a separate activity, for the maintenance program.
|
Plan of Correction
Kensington Hospital's Outpatient Program intends to request permission from the State to convert the Facility's drug free slots to maintenance slots. This would license the facility for an additional 40 methadone slots since the need for drug free is no longer a demand.
A letter will be sent by the Facility Director/Program Director to the State requesting this by 1/8/2010. The Facility will follow up with the State within 30 days for a status report.
In the event an increase is not granted by the State, staff will make appropriate referrals to other treatment providers for overage. |
715.6(b)(1-9) LICENSURE Physician Staffing
(b) A narcotic treatment program may employ narcotic treatment physicians to assist the medical director. A narcotic treatment physician 's responsibilities include:
(1) Performing a medical history and physical exam.
(2) Determining diagnosis and determining narcotic dependence.
(3) Reviewing treatment plans.
(4) Determining dosage and all changes in doses.
(5) Ordering take-home privileges.
(6) Discussing cases with the treatment team.
(7) Issuing verbal orders pertaining to patient care.
(8) Assessing coexisting medical and psychiatric disorders.
(9) Treating or making appropriate referrals for treatment of these disorders.
|
Observations
Based on the review of administrative documentation and discussion with staff, the facility failed to ensure the narcotic treatment physician had a current Drug Enforcement Administration (DEA) registration.
The findings include:
The personnel information for the physician was reviewed on November 16, 2009. The most recent DEA registration for the narcotic treatment physician expired March 31, 2009. The facility director reported it had been renewed and a copy would be acquired for review. A copy of a current DEA registration for the physician was not provided during the inspection.
|
Plan of Correction
The Narcotic Treatment Physician has a current DEA license with an expiration date of 3/31/2012. A copy of the physician's DEA license can be faxed upon request.
To assure this does not reoccur within the organization, the Medical Staff Coordinator will have a second individual also review the credentials listing to assure continued compliance of having current documentation on all physicians. |
715.10(b) LICENSURE Pregnant patients
(b) A narcotic treatment program shall give pregnant patients the opportunity for prenatal care either by the narcotic treatment program or by referral to appropriate health-care providers.
|
Observations
Based on the review of patient records, the facility failed to document the provision of prenatal care in one of two patient records.
The findings include:
Two patient records were reviewed on November 17, 2009 for the provision of prenatal care. Patient # 4 contained documentation in the annual physical exam by the physician on June 26, 2009 that the patient was referred to Thomas Jefferson Hospital for prenatal care. There was no further information found in the record to substantiate that the patient was actually receiving prenatal care. The patient had not yet delivered at the time of the visit.
|
Plan of Correction
The clinical staff will be provided with an in-service on Continuity of Care by 1/15/2010. In addition, staff will be reminded that all patients with special needs must be referred to the Case Manager for additional services.
The Clinical Supervisor will conduct a monthly chart review for six (6) months to identify patients with special needs to confirm the counselors are compliant in referring to the Case Manager when appropriate.
The first chart review was completed1/15/2010. |
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 pre-natal support in one of two patient records reviewed.
The findings include:
Two patient records were reviewed for documentation of prenatal support on November 17, 2009. Patient record # 4 did not contain any documentation of prenatal support.
|
Plan of Correction
The facility will document all pre-natal support provided in house and/or by other providers. All required information was received by patient #4 and has been filed in the patient chart since 12/09.
The Counseling staff will insure prenatal services are provided within the 1st trimester either by referral or in-house. This will be documented on the DAP notes.
The Clinical Supervisor will monitor throughout pregnancy for a period of 12 months via chart reviews. The first chart review was completed 1/2010 and will continue to be monioted as needed. |
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 the review of patient records, the facility failed to ensure at least monthly random urine drug screens for five of nine patient records.
The findings include:
Nine patient records were reviewed for monthly urine drug screen results on November 16-17, 2009.
Patient record # 4 did not have a urine drug screen for October 2009.
Patient record # 5 did not have a urine drug screen for October 2009.
Patient record # 6 did not have a urine drug screen for June and October 2009.
Patient record # 7 did not have a urine drug screen for September and October 2009.
Patient record # 18 did not have a urine drug screen for September and October 2009.
|
Plan of Correction
Monthly urine drug screens are being done. Staff were behind on filing documents. Also, the staff will be in-serviced immediately on the importance of filing and maintaining current charts.
The Clinical Supervisor will conduct monthly chart reviews for six (6) months to assure compliance.
The first chart review was completed 1/31/2010. |
715.23(b)(8) LICENSURE Patient records
(b) Each patient file shall include the following information:
(8) The patient 's current and past narcotic dosage level.
|
Observations
Based on the review of patient records, the facility failed to document patient's current and past narcotic dosage levels in four of thirteen patient records.
The findings include:
Thirteen patient records were reviewed for past and current narcotic dosage levels on November 16-17, 2009.
Patient record # 5 did not have any medical notes documented, making it impossible to determine the patient's current narcotic dose level.
Patient record # 6 did not have any medical notes documented, making it impossible to determine the patient's current narcotic dose level.
Patient record # 7 did not have any medical notes documented, making it impossible to determine the patient's current narcotic dose level.
Patient record # 8 did not have any medical notes documented, making it impossible to determine the patient's current and past narcotic dose level.
|
Plan of Correction
The Medical Director personally spoke with this particular physician on 11/18/09, as well as, sent a written memo to the physician instructing the physician to document on the Progress Note the reason why there is an increase/decrease in a client's methadone dosage.
A Performance Improvement Study will be conducted for a period of six (6) months to assure compliance by the physician.
The first study will be completed by 1/30/2010. |
715.23(b)(11) LICENSURE Patient records
(b) Each patient file shall include the following information:
(11) Counselor notes regarding patient progress and status.
|
Observations
Based on the review of patient records, the facility failed to maintain current progress notes in three of eight patient records and did not document complete group progress notes in three of eight patient records.
The findings include:
Eight patient records were reviewed for documentation of patient's progress. Three patient records did not have current information:
# 5 had no progress information since 9-1-09.
# 6 had no progress information documented since 10-6-09. In addition, this patient's treatment plan stated the patient would be attending 2 groups a week and the last documentation of group attendance was 7-24-09.
# 17 had no documentation of patient's status since 9-30-09.
These patients were current patients at the time of the inspection.
|
Plan of Correction
Current Progress Notes are currently being done. Staff was immediately in-serviced by the Clinical Supervisor on the importance of maintaining current progress notes.
The Clinical Supervisor will then conduct monthly chart reviews for six (6) months to assure compliance.
The first chart review was ompleted 1/15/2010. |
715.23(b)(13) LICENSURE Patient records
(b) Each patient file shall include the following information:
(13) Patient record of services.
|
Observations
Based on the review of patient records, the facility failed to maintain a complete patient record of services in five of eight patient records.
The findings include:
Eight patient records were reviewed for documented record of services. Five patient records did not have complete record of services.
Patient record # 4's documentation of a records of services was not documented chronologically and the last documentation of any service provided was dated 9-2-09. The record was listed as an active record.
The last documentation of service provided for patient record # 5 was 9-1-09. The patient was listed as active and the record contained documentation of daily dosing of the patient through 10-30-09.
Patient record # 6: the last documented service was dated 10-6-09. The record was listed as an active record.
Patient record # 17: the last documented service was dated 9-30-09. The record was listed as an active record.
Patient record # 18: the last documented service was dated 9-18-09. The record was listed as an active record.
|
Plan of Correction
The staff will be in-serviced immediately on the importance of Documented Record of Services for each client. The Clinical Supervisor will conduct monthly chart reviewed for six (6) months to assure compliance by the staff. The first chart review will be completed by 1/31/2010. |
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 and administrative documentation, the facility failed to ensure the psychosocial evaluations were a clinical assessment of the historical data collected in four of five.
The findings include:
Five patient records were reviewed for psychosocial evaluations.
Patient record # 5 was admitted and the biopsychosocial history was obtained June 13, 2009. The evaluation contained a repeat of the data, patient reported commentary and no clinical assessment.
Patient record # 6 was admitted May 20, 2009. The evaluation contained a repeat of the data, patient reported commentary and no clinical assessment.
Patient record #7 was admitted August 28, 2009. The evaluation was illegible and compliance was impossible to determine.
Patient record # 17 was admitted September 15, 2009. The evaluation contained a repeat of the data, patient reported commentary and no clinical assessment.
|
Plan of Correction
The staff will be in-serviced by the Clinical Supervisor by 1/15/2010 on Proper Documentation. Staff also received training on the Completion of the BioPsychosocial by the Department of Behavioral Health in March 2009, however a refresher course will be given by Joe DiMeo from the Department of Behavioral Health on 1/21/2010.
The Clinical Supervisor will monitor for compliance during Staff Supervisions and a review of the BioPsychosocial. Other counselor weaknesses will also be discussed at this time in order to maintain improvement. |
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 the review of patient records, the facility failed to complete annual evaluations in accordance with the regulations in four of four patient records reviewed.
The findings included:
Four patient records were reviewed for documentation of annual evaluations on November 16, 2009.
Patient record # 4 was to have an annual evaluation by 7-23-09. It was documented 8-19-09 and was not signed by the medical director or any physician.
Patient record # 13 was to have an annual evaluation by 9-11-09. It was documented 10-13-09 and was not signed by the medical director or any physician.
Patient record # 14 was to have an annual evaluation by 6-24-09. It was documented 7-23-09 and was not signed by the medical director or any physician.
Patient record # 15 was to have an annual evaluation by 7-18-09. There was no annual evaluation completed at the time of the visit.
|
Plan of Correction
An in-house policy has been implemented in which the Senior Secretary has monthly censuses with all patient names and dates of admission. She then reviewed it on a weekly basis and sents out a memo as a reminder when annual paperwork is due, (with all required paperwork attached to the memo). The reminder will be sent two (2) weeks prior to the actual due date.
The Clinical Supervisor receives a list of annual evaluations due for the month and will review charts monthly to insure completion.
The Clinical Supervisor will monitor for compliance through monthly chart reviews for six (6)months to assure compliance.
The first chart review was done 1/3/2010. |
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).
|
Observations
Based on a review of patient records, the facility failed to document the progress or lack of progress in achieving the goal statements from the prior treatment plan or were completed every 60 days per regulation in four of eight patient records.
The findings include:
Eight patient records were reviewed for treatment plan update documentation.
Patient records # 4, and 13 did not have the required treatment plan updates. Patient record # 4 did not contain documentation of a treatment plan update that was due by 10-19-09. Patient record # 13 did not contain documentation of a treatment plan update due by 10-16, 2009.
Patient records # 5 and 14 did not document patient progress towards meeting their respective goal statements, but rather contained generalized progress in the program. Goals were dropped without documentation of the reason. Goal status could not be identified in the treatment plan updates.
|
Plan of Correction
Staff will be in-serviced immediately on the importance of documentation of treatment plan updates.
The Clinical Supervisor will then conduct monthly chart reviews for six (6)months to assure compliance by the staff.
The first chart review was completed 12/15/09. |