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 March 29-31, 2011 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.
|
Plan of Correction
|
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).
|
Observations
Based on a review of patient records, the facility failed to obtain an informed and voluntary consent from the patient prior to the disclosure of information in eight of eleven patient records.
The findings include:
Twenty eight patient records were reviewed on March 4, 29-31, 2011. Eleven patient records were reviewed for the proper execution of an informed and voluntary consent from the patient prior to the disclosure of information. Nine of the eleven patient records, # 3, 4, 5, 6, 13, 17, 18 and 23 did not include consents consistent with the regulations for providing information with patient consent.
Patient record # 3 included consents to release that did not have the patient's signature, what specific information was being released and whether the patient was offered a copy.
Patient record # 4 included consents to release that did not include what specific information was being released and whether the patient was offered a copy.
Patient record # 5 included consent to release form that did not have the patient's signature, identification of specific information being released, and whether the patient was offered a copy.
Patient record # 6 included consents to release that did not have the patient's signature, what specific information that was being released and whether the patient was offered a copy.
Patient record # 13 included consents to release that did not have the specific information that was being released, whether the patient was offered a copy or who was to receive the information being released.
Patient record # 17 included consents to release that did not have the specific information that was being released, whether the patient was offered a copy or who was to receive the information being released.
Patient record # 18 included consents to release that did not have the specific information that was being released, whether the patient was offered a copy or who was to receive the information being released.
Patient record # 23 included consents to release that did not have the specific information that was being released, whether the patient was offered a copy or who was to receive the information being released.
|
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, is responsible for ensuring that patient files maintain confidentiality and contain valid consents prior to the release of patient information.
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 and full completion of consents to release information.. This will include training on 1) ensuring signatures are in place, 2) identification of whether or not the patient was offered a copy, 3) what information the patient consents to be released, and 4) who the information is being released to.
This training will take place by May 15, 2011
Monitoring:
The Facility Director, Clinical Supervisors, and Clinical Counseling staff will review client files during monthly supervision to ensure compliance with this standard.
|
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
|
Observations
Based on the review of patient information, review of administrative documentation and discussion with staff, the facility failed to demonstrate the patient's photograph was updated every three years.
The findings include:
The review of the electronic dosing records was conducted on March 31, 2011, beginning at approximately 9:15 AM. The electronic records include a photograph of the patient. There was no date on the document that identified when the photo was taken. The nursing director was interviewed about the process of updating the patient's photograph during this review. While the nursing director stated the photographs were updated sometime last year, there was no way to make this determination.
The policy and procedure manual was reviewed on March 31, 2011 at approximately 10:30 AM. The policy identified as OTP-715:13 states the photo identification card will show an expiration date. There were no expiration dates identified on the photo identification cards.
|
Plan of Correction
Plan of Correction: M099
715.13(b)
Patient identification:
Responsible Party(s): The intake worker and the nursing department is responsible for ensuring that all patients enrolled in the program have a valid photo taken, and updated every 3 years.
Timeframe for Completion:
The intake worker will be responsible for taking all patient photos at the point of intake, and updating every 3 years. Intake will also place a message in AMS that the photo has been taken or updated. The message screen has a date stamp on it, which will allow persons to view the date the photo was actually taken. The expiration date will also be added in AMS.
Monitoring:
The Facility Director, Nursing dept, and Intake Worker, will review AMS photo expirations on a weekly basis to ensure all photos remain current.
|
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
|
Observations
Based on a review of patient records, the facility failed to document the physician's dosage review at least twice a year in two of seven patient records.
The findings include:
Twenty eight patient records were reviewed March 4, 29-31, 2011. Seven patient records required the twice a year dosage level review to determine the patient's therapeutic dosage. Two of the patient records did not have the dosage review as required.
Patient # 4 was admitted March 12, 2004. The last two documented dosage reviews were done September 28, 2009 and September 27, 2010.
Patient # 22 was admitted June 18, 2001. The last two documented dosage reviews were done December 5, 2009 and then December 15, 2010.
|
Plan of Correction
Plan of Correction: M113
Medication Dosage:
Responsible Party(s):
The narcotic treatment physician is responsible for ensuring that all patients enrolled in the program have their dosage reviewed at least twice per year, at least two months apart.
Timeframe for Completion:
The Medical Director will be responsible for ensuring that the narcotic treatment physician documents all medication checks and dosage reviews for all patients at least twice per year.
The Nursing Supervisor will ensure scheduling for the physician for all persons due for a dosage review.
The narcotic treatment physician will receive training for dosage reviews by May 15, 2011.
Monitoring:
The Medical Director, will review records monthly of those persons scheduled for dosage reviews and ensure they are being conducted and documented as required.
|
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.
|
Observations
Based on the review of patient records, the facility failed to transfer the required patient files in three of four patient records.
The findings include:
Twenty eight patient records were reviewed March 4, 29-31, 2011. Five patient records required that the facility transfer specific patient files to the receiving narcotic treatment program as part of the transfer process. The facility did not document that the specified files were transferred in two patient records, patient # 22 and 24.
Patient # 22 was admitted June 18, 2001. The patient was transferred in February 2011. There was no documentation demonstrating what information was provided to the new facility.
Patient # 24 was admitted January 27, 2010. The patient was discharged as a transfer December 3, 2010. There was no documentation demonstrating what information, if any, was provided to the new facility.
Discussion with facility staff confirmed the documentation was not in the record.
|
Plan of Correction
Plan of Correction: M193
715.20(1): Patient transfers
Responsible Party(s):
Medical Records 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 information 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 will be responsible for training Medical Records Staff on the submission of the required documentation to the receiving facility of transferred patients by May 22, 2011.
The current policy will be updated to reflect this change by May 15, 2011.
Monitoring:
The Clinical Supervisors 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.
|
715.22(a) LICENSURE Patient grievance procedures
(a) A narcotic treatment program shall develop and utilize a patient grievance procedure.
|
Observations
Based on the review of administrative documentation and discussion with administrative staff, the facility failed to demonstrate a patient grievance procedure was developed and utilized.
The findings include:
The policy and procedure manual was reviewed on March 4, 2011 and again on March 31, 2011. There was no policy addressing grievances in the manual. Administrative staff reviewed the manual and confirmed the policy was not in the manual as required.
|
Plan of Correction
Plan of Correction:
M207
Responsible Party(s):
The Facility Director is responsible for ensuring that staff and members are aware of the grievance procedure.
The Facility Director is also responsible for ensuring that the procedure is found in the policy and procedure manual
Timeframe for Completion:
The Facility Director has placed the grievance procedure/policy in the facility manual as of April 1, 2011.
Monitoring:
The Facility Director will review policy and procedure manual once per month to ensure all policies and procedures are current and located in the manual as required.
|
715.23(b)(14) LICENSURE Patient records
(b) Each patient file shall include the following information:
(14) Case consultation notes regarding the patient.
|
Observations
Based on the review of patient records and discussion with facility staff, the facility failed to complete case consultations as required in seven of eleven patient records.
The findings include:
Twenty four patient records were reviewed on March 4, 29-31, 2011. Eleven patient records were reviewed for case consultations. Case consultations are required at least quarterly the first year in treatment and then at least annually each year thereafter.
Patient # 3 was admitted January 2, 2008. The last documented case consultation was completed October 9, 2008.
Patient # 6 was admitted May 30, 1996. The last documented case consultation was completed July 16, 2009.
Patient # 7 was admitted February 14, 2008. The last documented case consultation was completed May 7, 2010.
Patient # 8 was admitted December 16, 2010. There have been no consultations documented since the patient was admitted.
Patient # 12 was admitted October 2, 2002. The last documented case consultation was completed April 2, 2009.
Patient # 17 was admitted October 22, 2003. The last documented case consultation was completed January 13, 2010.
Patient # 24 was admitted January 22, 2010. The last documented case consultation was completed July 11, 2010.
|
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.
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 May 15, 2011.
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 Clinical Supervisors and the Facility Director will review patient records bi-weekly to monthly to ensure continued compliance with this standard.
|
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
|
Observations
Based on a review of patient records, the facility failed to document all of the required information in five of ten patient records.
The findings include:
Twenty eight patient records were reviewed March 4, 29-31, 2011. Ten patient records were reviewed for discharge summaries containing all of the required elements.
Patient # 15 was admitted May 6, 2009. Patient was discharged July 30, 2010. The reason(s) for patient's admission were generalized to the patient's opiate addiction and not the events that actually caused the patient to seek treatment when he/she did. The response to the treatment process was a general statement focused on the patient's drug use without any discussion of the patient's work during the entire treatment process.
Patient # 17 was admitted October 22, 2003. Patient was discharged March 8, 2011. The reason(s) for patient's admission were generalized to the patient's opiate addiction and not the events that actually caused the patient to seek treatment when he/she did. The response to the treatment process was a general statement focused on the patient's drug use without any discussion of the patient's work during the entire treatment process. The services offered did not include all of the services documented in the record or that the program offers to everyone registered for treatment.
Patient # 18 was admitted September 29, 2005. Patient was discharged December 3, 2010. The reason(s) for patient's admission were generalized to the patient's opiate addiction and not the events that actually caused the patient to seek treatment when he/she did. The response to the treatment process was a general statement focused on the patient's drug use without any discussion of the patient's work during the entire treatment process. The patient was known by facility staff to be deceased November 12, 2010, but the discharge summary was not completed within the seven days as required by regulation.
Patient # 23 was admitted August 11, 2010. Patient was discharged October 22, 2010. The response to the treatment process was a general statement focused on the patient's drug use without any discussion of the patient's work during the entire treatment process.
Patient # 24 was admitted January 27, 2010. Patient was discharged December 3, 2010. The response to the treatment process was a general statement focused on the patient's drug use without any discussion of the patient's work during the entire treatment process. There was no documentation of the patient's status at discharge.
|
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 May 15, 2011
Monitoring:
The Clinical Supervisors will be responsible for providing bi-weekly to monthly supervision to Clinical Staff ensuring that discharge summaries 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
|
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 six patient records reviewed.
The findings included:
Twenty-eight patient records were reviewed March 4, 29-31, 2011. Six patient records were reviewed for documentation of an annual clinical review.
Patient # 3 was admitted January 2, 2008. The last annual evaluation was October 27, 2009 for January 2009. There were no other annual evaluations in the patient record at the time of the monitoring visit.
Patient # 6 was admitted May 30, 1996. The last annual evaluation was documented as July 21, 2009, but signed by the counselor May 17, 2009 and signed by other staff on July 21, 2009. There were no other annual evaluations since this one in the patient record at the time of the monitoring visit.
Patient # 7 was admitted February 14, 2008. The last annual evaluation was February 9, 2010. There was no annual evaluation for February 2011 in the patient record at the time of the monitoring visit.
Patient # 12 was admitted January 2, 2008. The last annual evaluation was October 27, 2009 for January 2009. There were no other annual evaluations in the patient record at the time of the monitoring visit.
|
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 May 15, 2011
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
|
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.
|
Observations
Based on the review of patient records and administrative documentation, the facility failed to prepare a treatment plan in two of three patient records.
The findings include:
Twenty eight patient records were reviewed March 4, 29-31, 2011. The policy and procedure manual was reviewed March 4, 2011 and again on March 31, 2011. The policy stated the treatment plan was to be completed within 30 days of the preliminary treatment plan.
Three patient records were reviewed for the preparation of the treatment plan.
Patient # 14 was admitted February 5, 2011. The preliminary treatment plan was completed February 17, 2011. The comprehensive treatment plan had not been completed at the time of this monitoring inspection.
Patient # 23 was admitted August 11, 2010. The preliminary treatment plan was completed August 12, 2010. The comprehensive treatment plan had not been completed at the time the patient was discharged October 22, 2010.
|
Plan of Correction
Plan of Correction:
M269
715.23(d): Patient records
Responsible Party(s):
Clinical Counseling Staff, and Clinical Supervisors are responsible for ensuring that treatment plans are completed within 30 days of the preliminary plan.
Timeframe:
The Facility Director and Clinical Supervisors will train Clinical Counseling staff regarding the completion of comprehensive treatment plans within 30 days of the preliminary plan as required, by May 15, 2011.
Monitoring:
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
|
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
|
Observations
Based on the review of administrative documentation and discussion with facility staff, the facility failed to file written unusual incident reports with the Department within 48 hours as required.
The findings include:
Administrative documentation reviewed on March 30, 2011, included the documentation of the unusual incidents recorded by the facility.
Patient # 9 was involved in a physical altercation on February 14, 2011. This altercation involved a weapon and the police were called and removed patient in a patrol car. This was not reported as required.
Patient # 10 came to the facility and reported she had been raped and robbed February 1, 2011. The patient was seen by the psychiatrist, who wrote a note for emergency responders to take and present to the hospital ER as 911 was called for the patient. The documentation reported the patient was confused and possibly impaired. This was not reported to the Department as required.
Patient # 25 was given a verbal notice on March 8, 2011 that he would be receiving a written notice of intent to terminate on March 9, 2011. He became combative and the police were called to remove patient from the property. This was not reported to the Department as required.
Patient # 26 presented for treatment on February 25, 2011. The patient appeared impaired to the point the facility called 911 to take patient to the hospital ER. Emergency responders came and the patient refused to go. The police came and intervened. This was not reported to the department as required.
Patient # 29 deceased January 13, 2011. This was not reported to the department as required.
Patient # 30 left a child in her vehicle while she was inside receiving services. The internal incident report stated the police came and the security went out to watch the child until the patient returned. This was not reported to the Department as required.
|
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 and Clinical Supervisors are 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
Timeframe:
The Facility Director will train the Clinical Supervisors by May 15, 2011, 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.
|