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 27-29, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Addiction Medicine and Health Advocates, Inc. 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 2, 2009.
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Plan of Correction
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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 a review of patient records, the facility failed to ensure monthly urinalysis for three of eight patient records.
The findings include:
Nineteen patient records were reviewed January 28-29, 2009. Random monthly urinalysis was reviewed in eight patient records. Patient # 3 did not have a urinalysis in June and October 2008; Patient # 7 did not have a urinalysis in December 2008; Patient # 16, who was transferred into the facility in August 2008 did not have a urinalysis completed in August 2008.
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Plan of Correction
AMHA has instituted a new procedure to get a drug screen on the first day of medication for all patients who transfer into the program. For existing patients, the nursing staff of AMHA will manually review the the computer generated drug screen list each month to make sure each patient is scheduled. Patients who have not had a drug screen by the end of the third week of the month, they will have a drug screen the last week of the month. If there is uncertainty as to whether a patient has had a drug screen, a second will be taken. The filing of hard copies into the patient record will be monitored by the Clinical Coordinator to make sure the records meet state standards. We will monitor the process as part of our quality record review which is a function of our Quality Improvement program.
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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.
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Observations
Based on a review of patient records, the facility failed to ensure the physician completed a semi-annual dose review in three of six patient records.
The findings include:
Nineteen patient records were reviewed on January 28-29, 2009. Semi annual dose reviews were required in six patient records. The facility did not ensure the physician completed a semi annual dose review in patient records # 7, the last being documented 2-10-06; # 10, the last being completed 11-14-07; and # 18, having dose reviews only once annually since 12-26-06.
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Plan of Correction
AMHA has revised the patient physical form to include dosage review by the physician at the time of their annual exam. Counselors will then be responsible for scheduling an additional review, at least two months after the physical. The Clinical Coordinator will be responsible for making sure this is getting done. We will review this procedure via chart reviews as part of our Quailty Improvement program. |
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 the review of patient records, the facility failed to document individualized progress notes in three of six patient records.
The findings include:
Nineteen patient records were reviewed on January 28-29, 2009. Individual progress notes were required in six patient records reviewed.
Patient record # 3 contained the same identical assessment for progress notes dated 12-10-08, 12-17-08, 1-6-09 and 1-21-09, though the data was different for each note.
Patient record # 4 contained the same plan for each note, even when the patient did not show for the appointed session.
Patient record # 7 contained identical progress notes from session to session.
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Plan of Correction
A staff meeting was held on 2/5/09 to review and the discuss the findings of the State visit. This item was specifically addressed with the clinical staff who write progress notes. As a result of the visit, the Clinical Coordinator has scheduled ongoing supervision meetings with clinicians to review the proper manner in which to complete individualized progress notes. In addition, our plan is to add this item to our internal quality recovrd review checklist for ongoing monitoring and performance improvement. The Clinical Coordinator will be responsible for overseeing this process and for making sure notes are being completed correctly. |
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 document case consultations in three of nine patient records.
The findings include:
Nineteen patient records were reviewed on January 28-29, 2009. Case consultations were required in nine patient records.
Patient # 3 was admitted 3-08 and had one case consultation documented on 6-17-08. The facility failed to document additional case consultations which were due on 9-17-08 and 12-17-08.
Patient # 5 was due for an annual case consult by August 2008, but did not have one.
Patient # 17 was admitted in March of 2005, discharged in December 2008, and the last case consultation was documented 9-16-06. Annual case consultation documentation was required for 2007 and 2008
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Plan of Correction
In a staff meeting held on 2/5/09, the frequency and proper completion of case consultations was reviewed with staff in detail. Additionally, AMHA will be conducting a training on all clinical documentation, including case consultations by the end of March 2009.
AMHA will implement a chart review procedure which includes the review of each patient with less than one year of treatment. The review will specifically look for quarterly case consultations. Additionally, those patients who are in treatment for more than one year, will be reviewed during our quality improvement chart review. We are in the process of developing an Excel spreadsheet to track the due dates of all case consultations. The Clinical Coordinator will be responsible for monitoring this procedure. |
715.23(b)(22) LICENSURE Patient records
(b) Each patient file shall include the following information:
(22) Aftercare plan, if applicable.
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Observations
Based on the review of patient records, the facility failed to document an aftercare plan in one of one patient records.
The findings include:
Nineteen patient records were reviewed on January 28-29, 2009. An aftercare plan was required in one record. The facility did not document an aftercare plan to include goals and time frames in patient record # 9.
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Plan of Correction
In view of the fact, that all discharges are reviewed and signed by the Clinical Coordinator, the Clinical Coordinator will review all aftercare plans for goals and time frames. Additionally, a training will be scheduled to address discharge/aftercare planning. The Clinical Coordinator will be responsible for implementation of this. |
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 document annual evaluations in three of six patient records.
The findings include:
Nineteen patient records were reviewed on January 28-29, 2009. Annual evaluations were required in six patient records.
The facility did not document an annual evaluation in patient records # 5, last one completed 8-14-07;
patient records # 10, the last evaluation completed 11-8-07;
patient records # 18 had no annual evaluations and had been a patient since at least 2006.
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Plan of Correction
In a staff meeting held on 2/5/09, the frequency and proper completion of annual evaluations was reviewed with staff in detail. Additionally, AMHA will be conducting a training on all clinical documentation, including annual evaluations, by the end of March 2009. We are in the process of developing an Excel spreadsheet to track the due dates of all annual evaluations. AMHA will also conduct a chart review to identify records that may be lacking an annual evaluation. The Quality Record Reviewer and Clinical Coordinator will be responsible for developing the spreadsheet and the Clinical Coordinator will be responsible for monitoring compliance with completion of annual evaluations. |
715.23(d)(1) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(1) The treatment plan shall identify the behavioral tasks a patient shall perform to complete each short-term goal.
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Observations
Based on the review of patient records, the facility failed to identify the behavioral tasks to complete each short term goal in two of three patient records.
The findings include:
Nineteen patient records were reviewed January 28-29, 2009. Treatment plans were reviewed for action steps in three patient records. Action steps to complete short term goals were not documented in patient records # 13 and 16.
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Plan of Correction
AMHA will schedule a treatment planning training to review proper development and implementation of treatment plans. The Clinical Coordinator will work with individual clinicians to improve their treatment plans during supervision sessions. An outside trainer (to be identified) and the Clinical Coordinator will be responsible for carrying this responsibility out. |