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 November 16-19, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health Systems 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 13, 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 the administrative assistant, the facility failed to provide at least one hour of physician time a week, on site for, every ten patients.
The findings include:
Physician time sheets and and census reports for the months of August, September, October and part of November 2010. There were insufficient onsite physician hours during August and September 2010.
The facility administrative assistant provided a printout for the months of August and September 2010.
The total census for August was 629. There were 21 discharges and 33 admissions during the month.
The total census for September 2010 was 657. There were 24 discharges and 34 admissions during the month.
The monthly census for November at the time of the monitoring was 687.
During the week of August 9-15, 2010, there were 56 physician hours documented.
During the week of August 30 to September 5, 2010, there were 54 physician hours documented.
During the week of September 6-12, 2010 there were 49 physician hours documented.
During the week of November 1-7, 2010, there were 42 physician hours documented.
During the week of November 8-12, 2010, no physician hours were documented for the monitoring.
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Plan of Correction
The program director has reviewed the monthly calendar with the medical director to ensure and schedule physician coverage at the treatment program. Effective immediately, the facility will provide on-site physician coverage of one hour per week for every ten patients in treatment. The program director and the medical director will be responsible for reviewing the physician's schedule on a weekly basis to ensure that all physician's coverage are available to patients.
The physician's time sheets will be kept in file as evidence that enough coverage is being provided. |
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 restrict the face to face determination and documentation of current dependency and evidence of one year history of addiction to the narcotic treatment physician in four of six patient records.
The findings include:
Twenty-nine patient records were reviewed November 16-18, 2010. Six patient records were reviewed for determination of eligibility for admission.
In patient record # 6, the narcotic treatment physician failed to document the basis for determining at least one year physiological dependency; the patient record contained documentation of a letter from the patient's mother that was included in the record as the sole determination of dependency. There was no documentation of dependency entered by the physician in the patient record.
In patient record # 7, the narcotic treatment physician failed to document the basis for determining at least one year physiological dependency; the patient record contained documentation of a letter from the patient's boyfriend that was included in the record as the sole determination of dependency. There was no documentation of dependency entered by the physician in the patient record.
Patient # 12 was admitted based on the documentation by the Certified Physician Assistant (PA-c). There was no documentation by the narcotic physician for this admission.
Patient # 13 was admitted to the narcotic treatment program October 5, 2010. The patient was in the project's residential program as a direct admission from jail on September 27, 2010. The patient had been in the narcotic treatment program previously, until incarcerated six months prior. The patient was not maintained while incarcerated. The criminal justice system completed an assessment and recommended the patient be admitted for narcotic maintenance. The patient's initial urine drug screen was negative for all illicit substances. The narcotic treatment physician documented on the urine drug screen results that the patient had been incarcerated for six months and this was the third admission since 2007.
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Plan of Correction
The Medical Director will screen and assess each patient to determine eligibility for admission to treatment. The Medical Director will make a face to face assessment of the patient to review the physical state of the patient and will document evidence of the one year history of addiction and or current opiate dependency in the AMS system and patient record. A print out copy of the AMS progress notes will be filed in the patient record. In order to monitor this process is being followed, the Program Director will complete chart reviews of new admissions on a monthly basis and during monthly meetings with the Medical Director. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document the consultation between the narcotic treatment physician determining the initial dose and the narcotic treatment physician extender performing the physical examination in one of one patient records.
The findings include:
Twenty-nine patient records were reviewed November 16-18, 2010. One patient record required a consultation between the physician extender who completed the intake physical exam and the narcotic treatment physician who determined the initial dose.
The physician documented an admission order to start the patient on 50 milligrams on July 27, 2010. The patient had been incarcerated for six months prior, and was maintained on 50 milligrams daily while incarcerated. The documentation sent to the receiving program confirming the patient's dose indicated the last date the patient had been dosed was July 23, 2010 at 50 milligrams.
The facility physician failed to document that a consultation had taken place to determine the continuation of the dose at admission.
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Plan of Correction
Effective immediately, the Medical Director will consult with the treament physician performing an examination to determine the patient's initial dose. The Medical Director is responsible for determining the initial dose. The consult will be documented in the AMS system by the Medical Director and a print out copy will be placed in the patient's record.
The Medical Director will provide training on the protocol for medicaion dosage to the treatment physicians by 12/19/10. The Program Director will be responsible for reviewing charts on a monthly basis to ensure that this process is being followed. |
715.16(b)(1-8) LICENSURE Take-home privileges
(b) The narcotic treatment physician shall consider the following in determining whether, in exercising reasonable clinical judgment, a patient is responsible in handling narcotic drugs:
(1) Absence of recent abuse of drugs (narcotic or non-narcotic), including alcohol.
(2) Regular narcotic treatment program attendance.
(3) Absence of serious behavioral problems at the narcotic treatment program.
(4) Absence of known recent criminal activity.
(5) Stability of the patient 's home environment and social relationships.
(6) Length of time in comprehensive maintenance treatment.
(7) Assurance that take-home medication can be safely stored within the patient 's home.
(8) Whether the rehabilitative benefit to the patient derived from decreasing the frequency of attendance outweighs the potential risks of drug diversion.
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Observations
Based on the review of patient records, the facility granted take home privileges despite the patient abusing illicit substances in one of one patient record.
The findings include:
Twenty-nine patient records were reviewed November 16-18, 2010. Three patient records were reviewed for take home status. Patient # 11 was admitted October 23, 2009. The patient had been granted take home privileges previously and they were expanded due to a medical exception during the summer 2010. The medical exception expired and the physician ordered the return to the previous three day take home schedule in July 2010. The patient submitted urine drug screens positive for marijuana on 6/21/10, 7/9/10, 8/18/10, 9/13/10 and 10/13/10
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Plan of Correction
Patient's must meet criteria for take home prior and during receiving any take homes. By 12/31/10, the medical director; clinical supervisors; and program director will review all take home schedules to ensure compliance. In addition, the clinical supervisors will perform quarterly reviews of the charts for patients with reduced schedule to ensure that patients continue to meet criteria for take home privileges. During these reviews, any patient not meeting the criteria will immediatley return to 7 day schedule. The program director and medical director will provide counselors with training on take home privileges by 1/15/11. |
715.22(a) LICENSURE Patient grievance procedures
(a) A narcotic treatment program shall develop and utilize a patient grievance procedure.
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Observations
Based on the review of patient records and administrative documentation, the facility failed to utilize the policy and procedure for the grievance procedure of the facility.
The findings include:
Twenty nine patient records were reviewed November 16-18, 2010. Three patient records were reviewed for documentation of written notice for the administrative transfers the treatment team had decided to initiate.
The binder with patient grievances and administrative discharges was reviewed November 16 and 17, 2010.
The policy and procedure manual was reviewed on November 16, 2010. The policy includes written notice to the patient with the patient being given 48 hours to appeal the decision.
Patient # 25 was admitted March 24, 2008. The patient was administratively transferred August 12, 2010. There was no written notification with an opportunity to appeal in the patient record or the grievance binder.
Patient # 27 was admitted May 21, 1998. The patient was discharged for non-compliance May 25, 2010. There was no written notification with an opportunity to appeal in the patient record or the grievance binder.
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Plan of Correction
Effective immediately, the patient grievance procedure will be folllowed by all employees. Patients being administratively discharge will receive written notification including the reason for termination. A copy of the written notification will be filed in the patient record. Patients will receive instructions with time frames for appeal process. Counselors will not initiate any client termination process without the approval of the clinical supervisor and program director. Clinical Supervisors will be responsible for reviewing charts on a monthly basis to ensure this process is being followed. |
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, the facility failed to complete case consultations as required in six of twenty patient records.
The findings include:
Twenty nine patient records were reviewed on November 16-19, 2010. Twenty patient records were reviewed for case consultations.
Patient # 9 was admitted August 19, 2009. There were no case consultations documented in the record.
Patient # 10 was admitted October 16, 2008. The last documented case consultation was October 16, 2009. There must be at least an annual case consultation after the first year in treatment
Patient # 17 was admitted April 14, 2009. The last documented case consultation was January 15, 2010. There should have been another by April 2010. The patient was discharged June 7, 2010 following incarceration.
Patient # 18 was admitted June 25, 2004. The last documented case consultation was December 24, 2008.
The patient was discharged September 2010 against medical advice.
Patient # 23 was admitted October 13, 2008. There was only one case consultation documented between the admission date and patient's discharge date for death on July 30, 2010. That case consultation was dated January 23, 2009.
Patient # 25 was admitted March 24, 2008. The last documented case consultation was September 24, 2009. The patient was discharged October 8, 2010 as a transfer.
Patient # 27 was admitted May 21, 1998. The last documented case consultation was January 26, 2009.
The patient was discharged May 25, 2010 for non-compliance. There should be a case consultation at least annually.
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Plan of Correction
Case Consultations will be completed on a timely basis. Once the case consultation is completed and signed by all clinical staff, it will be filed in the patient's record. This protocol includes active records and records ready for discharge. During weekly supervision with the counselors, the clinical supervisors will review charts to ensure the case consultations are being completed when due. The program director will provide an in-service training to staff on patient records by 01/31/11. |
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, the facility failed to document all of the required information in twelve of fourteen patient records.
The findings include:
Twenty-nine patient records were reviewed November 16-18, 2010. Fourteen patient records required complete discharge summaries.
Patient # 17 was admitted April 14, 2009. Patient was discharged June 7, 2010. The facility failed to document the reason for the patient's entry into treatment.
Patient # 18 was admitted June 25, 2004. Patient was discharged September 20, 2010. The facility failed to document the reason for patient entry into treatment, a response to the six years of treatment, all the services offered, including pharmacotherapy, or the status of the patient upon discharge.
Patient # 19 was admitted May 11, 2010. Patient was discharged September 8, 2010. The facility failed to document all of the services offered, including pharmacotherapy.
Patient # 22 was admitted December 23, 2008. Patient was discharged October 13, 2010. The facility failed to document the reason the patient entered treatment, and a response to the almost two years of treatment or all the services offered, including pharmacotherapy.
Patient # 23 was admitted October 13, 2008. Patient was discharged July 30, 2010. The facility failed to document a response to the almost two years of treatment.
Patient # 25 was admitted March 24, 2008. Patient was discharged October 8, 2010. The facility failed to document the reason the patient entered treatment.
Patient # 26 was admitted May 31, 2001. Patient was discharged June 16, 2010. The facility failed to document the reason the patient entered treatment and a response to the nine years of treatment.
Patient # 27 was admitted May 21, 1998. Patient was discharged May 25, 2010. The facility failed to document the reason the patient entered treatment, a response to the twelve years of treatment, and all the services offered, including pharmacotherapy or the status of the patient at discharge.
Patient # 28 was admitted May 31, 2001. Patient was discharged November 1, 2010. The facility failed to document the reason the patient entered treatment and a response to the nine years of treatment.
Patient # 29 was admitted December 20, 2004. Patient was discharged July 20, 2010. The facility failed to document the reason patient entered treatment and a response to the almost six years of treatment.
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Plan of Correction
Effective immediately counselors will document all of the required information in the discharge summary form. The discharge summary documentation will include but not limited to reason for patient seekinng treatment; services offered; pharmacology; response to treatment; status at time of discharge.
Clinical Supervisors will review all discharges for completion of documentation prior to signing the discharge summary. The program director will provide an in-service on patient record by 01/30/11. |
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 accordance with the regulations in four of eleven patient records reviewed.
The findings included:
Twenty nine patient records were reviewed November 16-18, 2010. Eleven patient records required documentation of an annual clinical review. Four were not completed.
Patient # 9 was admitted August 19, 2009. There was no annual clinical evaluation documented in the patient record.
Patient # 10 was admitted October 16, 2008. There was no annual clinical evaluation documented in the patient record for October 2010.
Patient # 11 was admitted October 23, 2009. There was no annual clinical evaluation documented in the patient record for October 2010.
Patient # 23 was admitted October 13, 2008. There was no annual clinical evaluation documented in the patient record.
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Plan of Correction
Counselors will complete an annual evaluation on each patient record on their anniversary date. Once the annual evaluation is reviewed, signed, and dated by the clinical supervisor and the medical director, it will be filed in the patient record.
During the weekly supervision, the clinical supervisor will review charts to endure compliance. The program director will provide an in-service on patient record by 01/30/11. |
715.23(d)(2) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Based on the review of patient records, the facility failed to ensure the review, reevaluation, modification and update of patient's treatment plan in five of seventeen patient records.
The findings include:
Twenty nine patient records were reviewed November 16-19, 2010. Seventeen patient records required updates of the treatment plan.
Patient # 9 was admitted August 19, 2009. There were no treatment plan updates documented in the patient record at the time of the monitoring.
Patient # 18 was admitted June 25, 2004. There were no treatment plan updates documented in the patient record since May 10, 2010. The patient discharged September 20, 2010.
Patient # 22 was admitted December 23, 2008. There were no treatment plan updates documented in the patient record since July 19, 2010. The patient discharged October 13, 2010.
Patient # 23 was admitted October 13, 2008. There were no treatment plan updates documented in the patient record since December 17, 2009. The patient discharged July 30, 2010.
Patient # 24 was admitted January 15, 2010. There were no treatment plan updates documented in the patient record April and June 2010. The patient discharged August 17, 2010.
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Plan of Correction
Counselors will complete treatment plan updates on or before 60 days. The treatment plan update will include a review of the previous treatment plan goals and interventions. During the weekly supervision with the counselor, the clinical supervisors will review three charts to ensure that the treatment plan updates are being completed as scheduled. The Program director will provide counselors with an in-service on patient records by 01/30/11. |