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 January 25-28, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Consortium 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 March 1, 2010.
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Plan of Correction
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of administrative documentation and discussion with administrative staff, the facility failed to provide at least one hour of physician time per week, on site for, every ten patients for fourteen of fourteen weeks reviewed.
The findings include:
Physician time sheets and and census reports for the months beginning August 24 to December 11, 2009 were reviewed on January 25, 2010. The facility is licensed to medicate 420 patients and the census during the time period reviewed was reported to have averaged 360 or more per week. There were insufficient onsite physician hours during all weeks reviewed.
The insufficient physician hours were discussed with the director on January 26, 2010.
During the week of August 22-28, 2009, the total physician time was documented as 33.5 hours .
During the week of August 29-September 4, 2009, the total physician time was documented as 33 hours
During the week of September 5-11, 2009, the total physician time was documented as 27.5 hours
There were no time sheets presented for the time period of September 12 to September 20, 2009.
Ten physician hours were documented during the weeks of September 21 to October 2, 2009.
The documented time sheets presented for review never showed more than 33.5 hours of onsite physician time per week, with the least number of hours being ten hours of onsite physician time.
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Plan of Correction
Plan of Correction
M025
715.6(d) Physician Staffing:
Responsible Party(s):
The Nursing Supervisor will be responsible for submitting weekly schedules for the narcotic treatment physicians 2 weeks in advance to ensure that the program provides at least 1 hour per week of onsite physician time for every ten patients.
Timeframe for Completion: Verification of Physician Staffing schedules will be submitted to the Facility Director two weeks in advance beginning March 15, 2010.
Monitoring:
The Medical Director, Facility Director and Nursing Supervisor will work collaboratively to monitor physician staff time to ensure that the program is providing at least 1 hour per week of onsite physician time for every ten patients at all times.
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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 ensure physician documentation that evidenced a 1 year history of addiction in two of three patient records.
The findings include:
Twenty one patient records were reviewed on January 25-28, 2010. Three records required documentation by the physician of evidence of a 1 year history of addiction. Two patient records failed to contain physician documentation to support evidence of at least one year history of addiction.
Patient record # 6 had documentation of patient statement as the evidence of 1 year history of addiction with no additional information provided.
Patient record # 18 had documentation that there was prior history of chemical dependency, but previous history was not found in the record.
Neither record contained physician documentation to support evidence of at least one year history of addiction.
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Plan of Correction
Plan of Correction:
M059
715.9(a)(4): Intake
Responsible Party(s):
The Medical Director will be responsible for ensuring that all narcotic treatment physicians are trained to properly justify and document current dependency and evidence of a 1 year history of addiction for each patient in order to determine eligibility for admission.
Timeframe for Completion:
The Medical Director will train all narcotic treatment physicians by March 15, 2010.
Monitoring:
The Medical Director, in conjunction with the Facility Director, will monitor all admission records to ensure that the record includes documentation of the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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715.10(d) LICENSURE Pregnant patients
(d) Within 3 months after termination of pregnancy, the narcotic treatment physician shall enter an evaluation of the patient 's treatment status into her record and state whether she should remain in comprehensive maintenance treatment or receive detoxification treatment.
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Observations
Based on the review of patient records, the facility failed to ensure the physician provide a post-partum review within 3 months of termination of the pregnancy in one of three patient records reviewed.
The findings include:
Three records of pregnant or recent pregnancy termination were reviewed on January 25, 2010. One record required a physician evaluation to determine continued comprehensive maintenance treatment or receive detoxification treatment.
Patient # 3 delivered her baby on September 21, 2009. There was no documentation by the physician of the evaluation at the time of the inspection.
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Plan of Correction
Plan of Correction:
M083
715.10(d) Pregnant patients:
Responsible Party(s):
The Medical Director will be responsible for ensuring that within 3 months after termination of patient pregnancy, the narcotic treatment physician documents an evaluation of the patient 's treatment status, as well as whether or not the patient will remain in comprehensive maintenance treatment or receive detoxification treatment.
The Nursing Supervisor will be responsible for ensuring that all pregnant patients are scheduled for a post-partum evaluation within 3 months of termination of pregnancy.
Timeframe for Completion:
The Medical Director will be responsible for ensuring that all narcotic treatment physicians are trained to document a 3 month post-partum evaluation by March 15, 2010.
Monitoring:
The Medical Director will provide ongoing supervision to the narcotic treatment physicians to ensure that post partum evaluations are completed within 3 months of termination of pregnancy.
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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 document consents to release information and maintain patient confidentiality according to 4 PA Code and 42 CFR in five of seventeen patient records.
The findings include:
Twenty one patient records were reviewed January 25-28, 2010. Seventeen patient records were reviewed for compliance confidentiality. Five patient records contained information that belonged to other patients.
Patient record # 4 contained information belonging to 3 other patients.
Patient record # 10 contained information belonging to 1 other patient.
Patient record #12 contained information belonging to 1 other patient.
Patient record # 19 contained information belonging to 1 other patient.
Patient record # 21 contained information belonging to 2 other patients.
Additionally, six patient records contained blank signed consents.
Patient record # 6 contained 2 signed blank consents to release information.
Patient record # 8 contained 9 signed blank consents to release information.
Patient record # 13 contained 4 signed blank consents to release information.
Patient record # 14 contained a signed blank consent to release information.
Patient record # 16 contained 4 signed blank consents to release information.
Patient record # 17 contained 3 signed blank consents to release information.
These records also contained other incomplete consents to release information, such as not documenting whether a copy was offered, missing the purpose and not including all the information needed for the funding entities.
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Plan of Correction
Plan of Correction:
M093
715.11 Confidentiality of patient records
Responsible Party(s):
Clinical Staff, including Clinical Supervisors, Intake staff, and Clinical Counseling staff, are responsible for ensuring that patient files maintain confidentiality and contain valid consents to release patient information.
Medical Records staff is responsible for ensuring that all documentation that is filed into the patient record belongs to the correct patient.
Time Frame for Completion:
The Facility Director and Clinical Supervisors will be responsible for ensuring that all Clinical staff, including intake staff, is trained on the proper completion of consents to release information by March 19, 2010.
The Facility Director will address the issue of misfiling documentation in the patient records which belong to other patients, with the Medical Records staff and document in supervisory notes by March 15, 2010.
Monitoring:
The Facility Director, Clinical Supervisors, and Clinical Counseling staff will review client files during bi-weekly to monthly supervision to ensure compliance with this standard.
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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.
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Observations
Based on the review of patient records, the facility failed to complete all required urine drug screens for three of nine patients.
The findings include:
Twenty one patient records were reviewed January 25-28, 2010. Nine patient records were reviewed for compliance with the completion of at least monthly urine drug screens on January 25-28, 2010.
Patient # 11 was admitted May 31, 2007 and discharged December 18, 2009. Urine drug screens were not found in the patient record for the months of June and September 2009.
Patient # 19 was transferred in from a residential facility November 5, 2009, where the patient had a urine drug screen in October 2009. There was no documentation of the patient submission for a urine drug screen in November 2009.
Patient # 21 had various admission dates in the patient record, but it was determined the patient had been there for several years. The last urine drug screen in the record was dated November 30, 2009.
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Plan of Correction
Plan of Correction:
M101
715.14(a): Urine testing
Responsible Party(s):
The Nursing Staff has the responsibility to ensure that all initial drug screening urinalysis for each prospective patient and random urinalysis at least monthly thereafter, are administered as required.
Timeframe for Completion:
The Nursing Supervisor will provide the Facility Director with a weekly report regarding the status of initial and/or monthly random urinalysis administration for each patient beginning March 15, 2010.
Monitoring:
The Nursing Supervisor, along with the Facility Director will review the status of all outstanding drug urinalysis screenings weekly. Weekly reporting will enable the Management staff to ensure that each client receives a urinalysis randomly each month, or upon admission, for all prospective patients.
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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 document consultations with staff by the physician for take home privileges in two of three patient records reviewed.
The findings include:
Twenty one patient records were reviewed January 25-28, 2010. Three patient records required a documented consultation by the physician with other involved staff for the take home privileges granted.
Patient # 3 was receiving one take home bottle per week. There was no documentation of a consultation.
Patient # 4 was receiving two take home bottles per week. There was no documentation of a consultation.
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Plan of Correction
Plan of Correction:
M129
715.16(a)(2): Take-home privileges
Responsible Party(s):
The Medical Director and Narcotic Treatment Physicians are responsible for determining whether a patient may be provided take home privileges after consultation with other staff involved in the patient's treatment.
Clinical Counseling Staff is responsible to consult with the Narcotic Treatment Physician upon submission of a request for patient take home medications.
Timeframe:
The Medical Director will be responsible for ensuring that medical staff is trained to document a case consultation with other members of the patient's treatment team by March 15, 2010.
Clinical Counseling Staff will be trained by the Facility Director and Clinical Supervisors on the documentation of a case consultation with medical staff prior to the granting of take home medications by March 19, 2010
Monitoring:
The Facility Director and Clinical Supervisors will review patient records during bi-weekly and/or monthly supervision to ensure compliance with this standard.
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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 document the patient's initial and subsequent schedule in five of six patient records reviewed.
The findings include:
Twenty one patient records were reviewed January 25-28, 2010. Six patient records were reviewed for documentation of the patient's dose and schedule. Patient records # 3, 4, 6, 17 and 18 did not have the patient's medication schedule documented on the physician orders.
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Plan of Correction
Plan of Correction:
M159
715.17(c)(1)(i-vi): Medication control
Responsible Party(s):
The Medical Director is responsible for ensuring that all treatment physicians document the patient's initial and subsequent medication schedules on all physician orders.
Timeframe:
The Medical Director will be responsible for training all narcotic treatment physicians on the documentation of patient's medication schedules by March 15, 2010.
Monitoring:
The Medical Director will monitor compliance with this standard through monthly supervision with the treatment physicians and monthly review of the patient records.
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715.20 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.
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Observations
Based on a review of administrative documentation, patient records and patient and staff interviews, the facility failed to initiate a transfer within 7 days when the patient requested it in one of one patient records reviewed.
The findings include:
A patient interview was conducted at approximately 9:15 AM on January 28, 2010. The patient was asked to describe the process by which the patients are registered to dose and how the process worked for the patient specifically after it was noted by this writer that the patient was told she was "on hold" until after group counseling. The patient explained that she had to take public transportation for 2.5 hours each way daily to be medicated and she had requested a transfer to a program closer to her home. The patient reported the facility had not acted on her request over the past several months. The patient was told she would not be accepted anywhere else because of her illicit drug use. The clinical supervisor was interviewed and he reported he did in fact see documentation by the patient's prior counselor trying to transfer the patient, and that he himself had tried and had documented his attempts in the patient record as well. The patient record was then reviewed, and no documentation was found showing that anyone had tried to initiate a transfer of the patient. The policy and procedure manual was reviewed on January 25, 2010 and specified a patient would be transferred within seven days of a request to transfer. The staff interview was conducted at approximately 10:40 AM on January 28, 2020. The facility failed to comply with the patient's request for a transfer.
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Plan of Correction
Plan of Correction:
M191
715.20: Patient transfers
Responsible Party(s):
The Clinical Counseling Staff and Clinical Supervisors are responsible for ensuring that all patient requests for transfer to another narcotic treatment program for continued maintenance, detoxification or other treatment activity is completed within 7 days of the patient's request.
The Clinical Counseling Staff is responsible for documenting all attempts to transfer the client to another program in the patient record
Timeframe:
The Facility Director and the Clinical Supervisors will be responsible to train Clinical Counseling Staff on the process of initiating, completing, and documenting all attempts to satisfy patient requests for transfer to another facility within the required 7 day timeframe by March 19, 2010.
Monitoring:
The Clinical Counseling staff will be responsible for alerting the Clinical Supervisors of all patient transfers within 24 hours of the patient request.
The Clinical Supervisor will be responsible for monitoring the status of all identified patient requests for transfer to ensure that the request is fulfilled within 7 days.
Monthly patient record reviews and ongoing clinical supervision will also be conducted by the Clinical Supervisors and the Facility Director to ensure compliance with this standard on an ongoing basis.
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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 a review of patient records, the facility failed to transfer patient files to another narcotic treatment provider in six of six patient records.
The findings include:
Twenty one patient records were reviewed on January 25-28, 2010. Six patient records required the transfer of patient files to a receiving narcotic treatment provider.
Patient record # 8 contained a fax cover sheet showing only 3 unspecified pages were faxed to the receiving facility, and there was no consent to show what information was approved by the patient to be sent.
Patient record # 9 had no documentation of any information being sent to the receiving facility. There was a consent to release information where the information to be released stated "program progress" and the purpose of the release listed the required information to be sent. There was no other documentation indicating information had been sent to the receiving facility.
Patient # 10 was transferred to an out of state narcotic treatment facility October 9, 2009. There was no documentation of patient files being transferred.
Patient # 13 was transferred to another narcotic treatment facility out of the Commonwealth of Pennsylvania in August 2009. A counselor note on August 6, 2009 stated that the counselor had spoken with the facility and the facility did not want any information until the patient actually moved to their state. There was another notation that the referral was confirmed on August 17, 2009. According to patient dosing records, the patient was not dosed at the facility since August 6, 2009.
Patient # 14 was transferred to another facility December 3, 2009 and there was no documentation of any information from the patient's file being transferred.
Patient # 15 was transferred November 2, 2009 as an administrative transfer. The consent listed the required information to be sent under the purpose of the consent. There was no documentation of any information from the patient's file being transferred.
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Plan of Correction
Plan of Correction:
M193
715.20(1): Patient transfers
Responsible Party(s):
Clinical Counseling Staff has the responsibility of ensuring that the records of patients being transferred to another narcotic treatment program for continued maintenance, detoxification or other treatment activity, have the required documentation transmitted to the receiving facility. This includes an admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, current status of the patient, as well as the written consent of the patient to be transferred.
Timeframe:
The Facility Director and the Clinical Supervisors will be responsible for training Clinical Counseling Staff on the submission of the required documentation to the receiving facility of transferred patients by March 19, 2010.
Monitoring:
The Clinical Supervisor will be responsible for reviewing all patient transfer documentation prior to the information being transmitted to another narcotic treatment facility in order to ensure that all required elements are present.
Monthly patient record reviews and ongoing clinical supervision will also be conducted by the Clinical Supervisors and the Facility Director to ensure compliance with this standard on an ongoing basis.
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715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document what materials were sent to the receiving narcotic treatment program in six of six patient records.
The findings include:
Twenty one patient records were reviewed on January 25-28, 2010. Six patient records required documentation of the materials sent to the receiving provider of the transfer. In patient records # 8 , 9, 10, 13, 14 and 15 there was no documentation of the materials sent to the receiving narcotic treatment program.
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Plan of Correction
Plan of Correction:
M197
715.20(3): Patient transfers
Responsible Party(s):
Clinical Counseling Staff has the responsibility of ensuring that any patient information transmitted to another narcotic treatment program for continued maintenance, detoxification or other treatment activity, is clearly identified in the patient record.
Timeframe:
The Facility Director and the Clinical Supervisors will be responsible for training Clinical Counseling Staff on the correct documentation of materials sent to the receiving program of a patient transfer by March 19, 2010.
Monitoring:
Monthly patient record reviews and ongoing clinical supervision will also be conducted by the Clinical Supervisors and the Facility Director to ensure compliance with this standard on an ongoing basis.
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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.
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Observations
Based on a review of patient records, review of administrative documentation and discussion with staff, the facility failed to follow the policy stated for maintaining patients in the program in two of three patient records reviewed.
The findings include:
Twenty one patient records were reviewed January 25-8, 2010. Three patient records were reviewed for involuntary terminations. The policy and procedure manual was reviewed January 25, 2010. the policy addressing involuntary terminations stated the facility would make every effort to retain the patient before involuntarily terminating a patient.
Patient # 8 was involuntarily terminated October 6, 2009 for allegedly abusing benzodiazapine. There were no interventions documented and the patient's treatment plan contained the same documentation of patient making some progress on 3/23/09; 5/23/09 and 7/20/09.
Patient record # 11 contained documentation by the physician ordering an involuntary detoxification for 23 days, starting May 12, 2009 because the patient missed two appointments for the annual physical and lab tests. In discussion with the nursing supervisor, it was determined that this was to be used as a "threat' to get the patient to comply.
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Plan of Correction
Plan of Correction:
M201
715.21: Patient termination
Responsible Party(s):
The Facility Director and Clinical Supervisors are responsible for ensuring that all involuntary terminations from the treatment program are initiated when all other efforts to retain the patient have been exhausted.
Timeframe: The records of all patients who are currently subject to an involuntary termination from the treatment program will be reviewed to ensure that all measures have been taken by the treatment program to retain the client in treatment. All patients, whose records do not have the required documentation of retention attempts, will be scheduled for a consultation with the Facility Director, Clinical Supervisors, and/or Counselor of record in order to develop and document strategies to maintain the client in treatment. This will be completed by April 9, 2010.
All staff will be trained by the program director regarding the agency's policy on involuntary terminations, which includes the fact that the program does not utilize the involuntary termination process as a "threat" to a non-compliant client. In fact, the agency, does not engage in any punitive involuntary terminations and/or detoxifications unless the client is violent in the clinic, preys on other clients, seriously threatens clients and/or staff, or sells drugs around the clinic. Training will take place by April 9, 2010
Monitoring:
All cases of patients subject to an involuntary termination from the program will be reviewed during bi-weekly to monthly supervision to ensure that all efforts to maintain the client have been discussed and documented in the patient record and in clinical supervision notes.
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715.23(a) LICENSURE Patient records
(a) A narcotic treatment program shall maintain patient records in conformance with 42 CFR 2.16 and 2.22 (relating to security for written records; and notice to patients of Federal confidentiality requirements) and State statutes and regulations. A narcotic treatment program shall maintain a complete file on the premises for each present and former patient of the narcotic treatment program for at least 4 years after the patient has completed treatment or treatment has been terminated. Files shall be updated regularly so that the information is current.
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Observations
Based on the review of patient records and discussion with clinical staff, the facility failed to ensure the patient records were complete and updated regularly with current information in seventeen of twenty one patient records reviewed.
The findings include:
Twenty one patient records were reviewed January 25-28, 2010. Twenty one patient records were required to have complete and current information.
Patient records # 2, 3, 4, 12 and 21 did not have annual evaluations in the records.
Patient records # 3, 4, 5, 6, 7, 8, 12, 14, 17 and 21 did not have the required case consultations.
Patient records # 3, 4, 5, 8, 15, 19 and 21 were missing treatment plan updates.
Patient records # 1, 3, 5, 6, 15, 18, 21 did not have current progress notes.
Patient records # 7, 8, 9, 12, 13, 14, and 15 did not have documented follow up contact attempt as required.
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Plan of Correction
Plan of Correction:
M213
715.23(a): Patient records
Responsible Party(s):
The Clinical Supervisors, Clinical Counseling Staff and Medical Records Staff are responsible for maintaining a complete file on site for each present and former patient of the narcotic treatment program for at least 4 years after the patient has completed treatment or treatment has been terminated.
Timeframe for Completion:
Clinical Counseling Staff will be trained by the Clinical Supervisors and the Facility Director regarding the timelines for completion of documentation as well as the importance of maintaining a complete and updated patient record. Training will be completed by March 19, 2010
Medical Records staff will receive documented supervision regarding the timelines for filing current documentation in the patient record by March 5, 2010.
Monitoring:
The Facility Director will provide weekly to bi-weekly supervision with the Medical Records Staff to review the status of filing and to ensure that all patient records have complete and current information.
The Clinical Supervisor will provide bi-weekly to monthly supervision with Clinical Counseling Staff to monitor the completion of required documentation and to ensure the smooth transition of the documentation from the Counselor of Record to the Medical Records office.
The Facility Director and the Clinical Supervisors will conduct monthly patient record reviews to ensure that all required documentation is fully completed and filed into the clinical record.
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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 narcotic treatment program failed to document the results of annual reevaluations by the narcotic treatment physician four of five patient records.
The findings include:
Twenty one patient records were reviewed on January 25-28, 2010. Annual reevaluations, as part of the annual history and physical by the narcotic treatment physician, were required in five patient records. The narcotic treatment program failed to document the results of the annual reevaluation by the narcotic treatment physician in patient records # 3, 4, 5 and 16.
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Plan of Correction
Plan of Correction:
M225
715.23(b)(5): Patient records:
Responsible Party(s):
The Medical Director is responsible for ensuring that all annual physical examinations that are conducted by the narcotic treatment program document the results of annual reevaluations by the narcotic treatment physician.
Timeframe:
The Program Director will provide training to the Medical Staff, including the Medical Director, and all narcotic treatment physicians to complete, and document, annual reevaluations as a part of the annual physical examination process by March 22, 2010.
Monitoring:
The Medical Director will be responsible for providing monthly supervision to all narcotic treatment physicians to ensure continued compliance in this area.
The Facility Director, Clinical Supervisor and the Medical Director will review patient records on a bi-weekly to monthly basis to ensure continued compliance.
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715.23(b)(11) LICENSURE Patient records
(b) Each patient file shall include the following information:
(11) Counselor notes regarding patient progress and status.
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Observations
Based on review of patient records, the facility failed to provide the required information regarding the patient's progress and status in the clinical notes in 7 of 11 patient records reviewed.
The findings include:
Twenty one patient records were reviewed January 25-28, 2010. Eleven patient records were reviewed for counselor notes regarding patient's status in treatment. Seven patient records did not provide current information on the patient's treatment status as required.
There were no progress notes documented in the patient record # 3 between May 13 and September 25, 2009.
There were no counselor's progress notes documented in the patient record # 4 since November 4, 2009.
There were no counselor's progress notes documented in the patient record # 5 since November 11, 2009.
There were no progress notes documented in the patient record # 15 between May 8, 2009 and January 27, 2010
Patient # 18 was admitted January 14, 2010 and there are no progress notes in the patient record.
Patient # 20 was admitted December 14, 2009. There were no individual counseling notes as of the inspection date.
There were no counselor's progress notes documented in the patient record # 21 since December 18, 2009. This patient is in the facility Intensive Outpatient Program (IOP) and attends the program daily.
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Plan of Correction
Plan of Correction:
M237
715.23(b) (11): Patient records
Responsible Party(s):
The Clinical Counseling Staff and the Clinical Supervisors are responsible for ensuring that the patient record includes Counselor notes regarding patient progress and status.
Medical Records staff is responsible for ensuring that Counselor notes are filed into the patient record once received from the Clinical Staff, and kept current.
Timeframe:
The Clinical Counseling staff and Clinical Supervisors will receive training regarding the importance of completing notes within 24 hours of the provision of the service delivered by March 19, 2010.
The Medical Records staff will be trained regarding the importance of filing Counselor Notes into the patient record in a timely manner by March 15, 2010.
Monitoring:
The Clinical Supervisors will be responsible for providing bi-weekly to monthly supervision to Clinical Staff ensuring that Counseling notes are kept current.
The Facility Director will provide weekly to bi-weekly supervision to the Medical Records staff to ensure timely filing of Counselor Notes into the patient record.
The Facility Director and Clinical Supervisors will review patient records on a bi-weekly to monthly basis in order to ensure continued compliance with this standard.
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715.23(b)(13) LICENSURE Patient records
(b) Each patient file shall include the following information:
(13) Patient record of services.
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Observations
Based on the review of patient records, the facility failed to maintain a complete patient record of services in seven of eight patient records reviewed .
The findings include:
Twenty one patient records were reviewed January 25-28, 2010. Eight patient records were reviewed for documented record of services. Seven patient records did not have complete record of services, patient records # 4, 5, 6, 11, 15, 18 and 19.
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Plan of Correction
Plan of Correction:
M241
715.23(b) (13): Patient records
Responsible Party(s):
The Medical Records Staff is responsible for ensuring that all patient files contain a complete patient record of services.
Timeframe:
The Facility Director will address this issue in supervision with Medical Records staff by March 5, 2010. Discussion will be documented in supervisory notes.
Monitoring:
The Facility Director will provide weekly to bi-weekly supervision with the Medical Records staff to ensure that current records of service are contained in the patient record.
The Clinical Supervisors and the Facility Director will review patient records bi-weekly to monthly to ensure continued compliance with this standard.
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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 and administrative documentation, the facility failed to complete case consultations according to policy or as required in twelve of eighteen patient records.
The findings include:
The policy and procedure manual was reviewed January 25, 2010. The program policy for completing case consultations states they will be completed at least every six months.
Twenty one patient records were reviewed January 25-18, 2010. Eighteen patient records were reviewed for case consultations.
Patient # 4 was admitted 1-2-2008 and had no case consultation documented in the record since October 2, 2008.
Patient # 5 was admitted 7-11-2006 and the last documented case consultation in the record was dated January 2009.
Patient # 6 was admitted 8-19-2009 and had no documented case consultation in the record.
Patient # 7 was admitted 5-6-2005 and the only documented case consultation in the record was dated April 30, 2009.
Patient # 8 was admitted 4-3-2007 and the last documented case consultation in the record was dated July 20, 2009, more than three months late.
Patient # 10 was admitted 11-15-88 and the last documented case consultation in the record was dated May 19, 2009. In addition, this case consultation consisted of check box questions and no discussion or summary.
Patient # 12 was admitted 7-10-2008 and the only documented case consultation in the record was dated January 7, 2009.
Patient #14 was admitted 5-20-2008 and the last documented case consultation in the record was dated May 7, 2009.
Patient # 15 was admitted 5-6-2008 and documented case consultation in the record was dated July 9, 2009, two months late.
Patient # 16 was admitted 4-3-2007. The form used to document case consultations is a check list of questions regarding progress in some areas of patient's treatment. There is no discussion or summary documented to demonstrate this was a case consultation.
Case consultations were missing from patient record # 17 and 21.
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Plan of Correction
Plan of Correction:
M243
715.23(b) (14): Patient records
Responsible Party(s):
The Clinical Counseling Staff and the Clinical Supervisors are responsible for ensuring that the patient record includes Case Consultation notes regarding each patient.
Medical Records staff is responsible for ensuring that Case Consultation Notes are filed into the patient record once received from the Clinical Staff.
Timeframe:
The Clinical Counseling staff and Clinical Supervisors will receive training regarding the importance of completing case consultation notes at least once per quarter during the patient's first year of treatment and annually thereafter, by March 19, 2010.
The Medical Records staff will be trained regarding the importance of filing Case Consultation Notes into the patient record in a timely manner by March 15, 2010.
Monitoring:
The Clinical Supervisors will responsible for providing bi-weekly to monthly supervision to Clinical Staff ensuring that Case Consultation Notes are completed as required.
The Facility Director will provide weekly to bi-weekly supervision with the Medical Records staff to ensure that current case Consultation Notes are filed in the patient record as required.
The Clinical Supervisors and the Facility Director will review patient records bi-weekly to monthly to ensure continued compliance with this standard.
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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 and administrative documentation, the facility failed to ensure the psychosocial evaluations were a clinical assessment of the historical data collected and done within the time frame of 30 days of admission stated in policy manual.
The findings include:
Twenty one patient records were reviewed on January 25-28, 2010. Three patient records were reviewed for psychosocial evaluations January 27, 2010.
Patient record # 20 was formally admitted December 14, 2009. Patient had been attending daily for dosing since December 1, 2009. An evaluation had not been completed at the time of the inspection.
Patient records # 6and 17 had psychosocial documents that contained a repeat of the data, patient reported commentary and no clinical assessment.
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Plan of Correction
Plan of Correction:
M245
715.23(b) (15): Patient records
Responsible Party(s):
Intake Staff is responsible for ensuring that all patient records contain a completed psychosocial evaluation, which includes a clinical assessment of the historical data collected, within 30 days of patient admission.
Timeframe:
The Facility Director will be responsible for ensuring that all Intake Staff is trained on the timeline for completion of the Psychosocial evaluation and the proper documentation of a clinical assessment of the historical data collected from the patient. This training will occur by March 15, 2010.
Monitoring:
The Facility Director will provide weekly to bi-weekly supervision with Intake staff to ensure that Psychosocial Evaluations are contained in the patient record as required.
The Clinical Supervisors and the Facility Director will review patient records bi-weekly to monthly to ensure continued compliance with this standard
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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 a review of patient records and facility policy and procedure, the facility failed to document a discharge summary within the facility's designated time frame of seven days in five of eleven patient records.
The findings include:
Twenty one patient records were reviewed January 25-28, 2010. Eleven patient records were reviewed for compliance with discharge summaries.
Patient records # 1, 2, 9, 10, 11, 12, 13, 14 and 15 did not specify the reason or reasons the patient entered treatment when they did, but rather documented a general statement such as opiate dependence or patient was tired of being tired.
Patient records # 1, 2, 7, 8, 9, 10, 11, 12, 13, 14 and 15 did not document a response to the treatment process, but a general statement focused on the discharge reason or attendance and substance use patterns of the patient.
Patient records # 1, 9, 11, 12, 14 and 15 did not document all services offered to the patient during the course of their treatment, specifically the main purpose of medicated assisted treatment.
In addition, patient # 2 was discharged on September 14, 2009, more than two weeks after the family notified the facility of the death of the patient on August 28, 2009.
Patient # 13 was given an administrative transfer on August 15, 2009 and the discharge summary was not completed until September 1, 2009.
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Plan of Correction
Plan of Correction:
M261
715.23(b)(23): Patient records
Responsible Party(s):
The Clinical Counseling Staff and the Clinical Supervisors are responsible for ensuring that a complete discharge summary is documented within seven days of patient discharge.
Timeframe:
The Facility Director and Clinical Supervisor will train the Clinical Counseling staff regarding the completion of a comprehensive discharge summary within seven days of discharge by March 19, 2010.
Monitoring:
The Clinical Supervisors will be responsible for providing bi-weekly to monthly supervision to Clinical Staff ensuring that discharge summarires are completed as required.
The Clinical Supervisors and the Facility Director will review patient records bi-weekly to monthly to ensure continued compliance with this standard
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715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on the review of patient records, the facility failed to document the attempt or completion of patient follow up contact in seven of nine patient records reviewed. .
The findings include:
Twenty one patient records were reviewed January 25-28, 2010. Nine patient records required follow-up documentation. Patient records # 7, 8, 9, 12, 13, 14 and 15 did not have documentation of patient follow up attempt or contact.
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Plan of Correction
Plan of Correction:
M263
715.23(b) (24) Patient records:
Responsible Party(s):
The Clinical Counseling Staff and the Clinical Supervisors are responsible for ensuring that follow up information, attempts and contacts are documented in the patient record for all discharged patients.
Timeframe:
The Facility Director and Clinical Supervisors will train the Clinical Counseling staff regarding the documentation of follow up information in the patient record by March 19, 2010.
Monitoring:
The Clinical Supervisors will be responsible for providing bi-weekly to monthly supervision to Clinical Staff ensuring that follow up is documented in the patient file as required.
The Clinical Supervisors and the Facility Director will review patient records bi-weekly to monthly to ensure continued compliance with this standard
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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 four of eleven patient records reviewed.
The findings included:
Twenty one patient records were reviewed January 25-28, 2010. Eleven patient records were reviewed for documentation of annual evaluations.
Patient # 2 was admitted April 7, 2004. There were no annual evaluations in the patient record at the time of the inspection.
Patient # 3 was admitted 1-24-09. There was no annual evaluation in the patient record.
Patient # 4 was admitted 1-2-08. There was no annual evaluation in the patient record.
Patient # 8 was admitted 4-3-07. The annual evaluation was completed July 17, 2009, but was not signed by the medical director..
Patient # 12 was admitted 7-10-08. There was no annual evaluation in the patient record.
Patient # 13 had an annual evaluation done May 20, 2009. It did not reflect the prior year, but rather the current situation of the patient and it was not signed by the medical director.
Patient # 15 was to have an annual evaluation by May 6, 2009. There was no annual evaluation completed at the time of the visit.
Patient # 16 had an annual evaluation April 17, 2009. It was not signed by the medical director.
Patient # 21 had been enrolled for several years. There was no annual evaluation completed at the time of the visit.
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Plan of Correction
Plan of Correction:
M267
715.23(c) (1-7): Patient records
Responsible Party(s):
The Clinical Counseling Staff and the Clinical Supervisors are responsible for ensuring that an annual evaluation of each patient's status is completed by the patient's counselor and reviewed, dated and signed by the medical director.
Timeframe:
The Facility Director and Clinical Supervisors will train the Clinical Counseling staff regarding the documentation of annual evaluations in the patient record for all clients who have been enrolled in the treatment project for more than one year, by March 19, 2010.
Monitoring:
The Clinical Supervisors will be responsible for providing bi-weekly to monthly supervision to Clinical Staff ensuring that annual evaluations are documented in the patient file as required.
The Clinical Supervisors and the Facility Director will review patient records bi-weekly to monthly to ensure continued compliance with this standard
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715.23(d) 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.
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Observations
Based on the review of patient records, the facility failed to complete a treatment plan in two of three patient records reviewed.
The findings include:
Three patient records were reviewed for treatment plans January 25, 2010. Patient # 6 was admitted August 19, 2009. A treatment plan was not documented in the patient record. Patient # 20 was admitted December 14, 2009. A treatment plan was not documented in the patient record.
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Plan of Correction
Plan of Correction:
M269
715.23(d): Patient records
Responsible Party(s):
The Intake Staff, Clinical Counseling Staff, and Clinical Supervisors are responsible for ensuring that treatment plans are completed and reviewed, as well as dated and signed by the medical director.
Timeframe:
The Facility Director and Clinical Supervisors will train the Intake and Clinical Counseling staff regarding the completion of comprehensive and updated treatment plans as required, by March 19, 2010
Monitoring:
The Facility Director will provide weekly to bi-weekly supervision with the Intake staff to ensure that Treatment plans are completed, and contained in the patient record as required.
The Clinical Supervisors will be responsible for providing bi-weekly to monthly supervision to Clinical Counseling Staff ensuring that treatment plans are completed and documented in the patient file as required.
The Clinical Supervisors and the Facility Director will review patient records bi-weekly to monthly to ensure continued compliance with this standard
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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 a review of patient records and staff interviews, the facility failed to document the progress or lack of progress in achieving the goal statements from the prior treatment plan in seven of ten patient records reviewed.
The findings include:
Twenty one patient records were reviewed January 25-29, 2010. Ten patient records were reviewed for treatment plan update documentation. Clinical supervisors stated the updates are to be completed every 30 days for those in IOP (intensive outpatient) services.
Patients # 5, 19 and 21 were identified as receiving IOP services.
Patient # 3 had multiple treatment plan update forms that were blank of any documentation other than a signature.
Patient # 4 was due to have an update by 1-9-2010. There was no documentation of a treatment plan update in the patient record.
Patient # 5 was identified as an IOP patient and the last update was dated 11-2-09.
Patient # 8 was discharged 10-6-09 and the last update was dated 7-20-09.
Patient # 15 was discharged administratively 11-2-09 and the last treatment plan update was 6-10-09.
Patient # 19 was identified as an IOP patient and was due to have a treatment plan update by 12-30-09. There was no documentation of a treatment plan update in the patient record.
Patient # 21 was identified as an IOP patient and was due to have a treatment plan update by 1-4-2010. There was no documentation of a treatment plan update in the patient record.
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Plan of Correction
Plan of Correction:
M273
715.23(d) (2): Patient records
Responsible Party(s):
The IOP Clinical Counseling Staff and Clinical Supervisors are responsible for ensuring that treatment plan updates are completed every 30 days, while the OP Clinical Counseling Staff and Clinical Supervisors, are responsible for ensuring that treatment plan updates are completed every 60 days. All plans are to be reviewed, dated and signed by the medical director as required.
The Clinical Counseling Staff and Clinical Supervisors are also responsible for ensuring that treatment plan updates document the progress or lack of progress in achieving the goal statements from the prior treatment plan.
Timeframe:
The Facility Director and Clinical Supervisors will train the Clinical Counseling staff regarding the completion of updated treatment plans as required, as well as the documentation of the progress, or lack of progress, made from the previous treatment planning period. Training will be conducted by March 19. 2010.
Monitoring:
The Clinical Supervisors will be responsible for providing bi-weekly to monthly supervision to Clinical Counseling Staff ensuring that treatment plans are completed as required and contain an evaluation of the patient's progress towards the last treatment plan's goals.
The Clinical Supervisors and the Facility Director will review patient records bi-weekly to monthly to ensure continued compliance with this standard
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715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
Based on observation, the facility failed to present the unusual incident reports to determine whether the facility is complying with their own procedures in response to unusual incidents.
The findings include:
The documentation of unusual incidents was requested on January 25 and 27, 2010. The documentation was not presented for review. The facility failed to maintain a record of incident report documentation.
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Plan of Correction
Plan of Correction:
M315
715.28(a) (1-10): Unusual incidents
Responsible Party(s):
All program staff who are employed by the agency are responsible for ensuring that all unusual incidents are documented within 24 hours of the incident and submitted to the Clinical Supervisor.
The Facility Director is responsible for ensuring that all unusual incidents that are identified in 715.28(a) (1-10): are documented and available for review upon request.
Timeframe:
Program Staff will be trained by the Facility Director and the Clinical Supervisors by March 19, 2010, in regards to the documentation of unusual incident reports.
Monitoring:
The Facility Director will retain copies of all unusual incident reports in the Director's office starting immediately.
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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 documentation, observation and staff interviews, the facility failed to submit an incident report to the Department within 48 hours.
The findings include:
In an interview, the facility director reported that counseling services were cancelled due to the facility heater breaking down in the beginning of the January 2010. Documentation in patient records demonstrated that counseling services were cancelled and staff left the facility early. During the monitoring visit, the facility ran out of oil on January 26 and 27, 2010. The lack of heat and disruption of services was not documented or reported to the Department as required.
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Plan of Correction
Plan of Correction:
M321
715.28(c)(1-5): Unusual incidents
Responsible Party(s):
All program staff who are employed by the agency are responsible for ensuring that all unusual incidents are documented within 24 hours of the incident and submitted to the Clinical Supervisor.
The Facility Director is responsible for ensuring that all unusual incidents that are identified in 715.28(c) (1-5) are documented and filed with the Department within 48 hours of the unusual incident. All copies of unusual incidents will also be available for review upon request.
Timeframe:
The Facility Director will train the Clinical Supervisors by March 19, 2010, in regards to the documentation of unusual incident reports and submission of the reports to the Department within 48 hours of the unusual incident.
Monitoring:
The Facility Director will retain copies of all unusual incident reports in the Director's office starting immediately.
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