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 March 29-31, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Family Center Of Thomas Jefferson University (MATER) 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 April 28, 2010.
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Plan of Correction
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715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
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Observations
Based on the review of patient record documentation, the facility failed to ensure the physician documented in the patient record the rationale for granting take home medication in three of three patient records.
The findings include:
Twelve patient records were reviewed on March 29-30, 2010. Three records were reviewed for take home medication documentation. Patient records # 10, 11 and 12 did not contain documentation of the physician's rationale for granting the take home medication.
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Plan of Correction
We have revised our annual physical form to include the following information for the physician's approval: 1) Permanent disability
2) temporary disability; 3) circumstances (illness, personal or family crisis, or travel which interferes with the mandatory attendenace schedules. Pt must be able to demonstrate responsible behavior particularly as it relates to handling narcotic drugs.
The physician must sign all requests for granting THB's. Once the exception has been signed, the physician will submit the request to the pharmacy for the requested changes.
As a mechanism to review all THB's based on the above, the Clinical Director and Nurse Coordinator will review these exceptions in weekly patient status meetings. This will add another balance and check system to insure all request have been submitted corrected; have been signed by the physician; and, in compliance with all regulatory requirements.
Timeframe for completion: immediate
Person(s) responsbile: Medical Director, Clinical Director and Nurse Coordinator |
715.16(d)(1-3) LICENSURE Take-home privileges
(d) A narcotic treatment program may make exceptions to the requirements in subsection (c) relating to the length of time of satisfactory adherence to narcotic treatment program rules and number of days of take-home medication when, in the reasonable clinical judgment of the narcotic treatment physician, which is documented in the patient record:
(1) A patient has a permanent physical disability.
(2) A patient has a temporary disability.
(3) A patient has an exceptional circumstance such as illness, personal or family crisis, or travel which interferes with the patient 's ability to conform to the applicable mandatory attendance schedules. In all cases, the patient shall demonstrate an ability to responsibly handle narcotic drugs.
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Observations
Based on the review of patient records, the facility failed to ensure the physician completed the exceptional circumstance documentation in one of three patient record reviewed.
The findings include:
Twelve patient records were reviewed on March 29-31, 2010. Three patient record were reviewed for exceptional circumstance take home medication documentation. Patient # 12 was admitted for treatment September 16, 2009. Patient was pregnant and delivered her infant on December 30, 2009 by Caesarean (C) Section. Patient was given 4 take home bottles initially. The patient developed medical complications and was granted a temporary medical exception and ordered by the physician to have 6 take home bottles for a two week period ending February 1, 2010. A review of patient record # 12 revealed that the patient has continued to receive 6 take home bottles per week without an exception by the physician.
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Plan of Correction
As a safeguard against possible misentries into the computer, all temporary medical exceptions will be carefully reviewed with all staff on a weekly basis during the patient status meeting. The medical director is part of this team meeting and will based on h/h resonable judgment authorize a continuation or non-continuation of THB's. The required prescription will be completed and approved by the medical director.
The weekly patient status meeting will serve to the the vehicle to check to ensure all exceptions have been appropriately entered into the AMS. Also, weekly reviews of the Patient Profile will indicate the THB schedules for patients on a medical exception. This will be reviewed weekly in the patient status meeting.
Timeframe for completion: Immediate
Person(s) Responsible: Nurse Coordinator and Clinical Supervisor |
715.16(e) LICENSURE Take-home priveleges
(e) With an exception granted under subsection (d), a narcotic treatment program may not permit a patient to receive more than a 2-week take-home supply of medication.
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Observations
Based on a review of patient records, the facility failed to restrict the exceptional take home bottles to no more than 14 bottles.
The findings include:
Twelve patient records were reviewed March 29-30, 2010. Patient # 1 is on a 13 take home bottle schedule as approved by the Division, but she received a split dose and was actually receiving 27 bottles every 2 weeks.
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Plan of Correction
Program had based request on 13-day interpretation to mean "days". Staff have been notified that 13-day means 13 bottles and if a patient is on a split-dose, they do not meet the exception requirement for the 13-day THB's regulation. The patient will be given 6 day THBs' not to exceed 14 bottles.
Timeframe for completion: Immediate
Person(s) responsible: Counselor, Medical Director, and Clinic Director |
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 review of patient records, the facility failed to ensure all efforts had been initiated to retain the patient prior to the involuntary termination in one of two patient records.
The findings included:
Twelve patient records were reviewed March 29-30, 2010. Two patient records were reviewed for involuntary termination documentation. Patient # 2 was admitted June 24, 2009. Patient was terminated March 22, 2010 for using her son's urine for her program required urinalysis drug screen. There was no documentation of any therapeutic interventions addressing the behavior prior to the administrative termination.
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Plan of Correction
The Clinical Director has reviewed the procedures for termination of a patient which must be based on behaviors, and the clear documented behavorial interventions that were discussed and implemented, prior to an adminstrative discharge.
Any administrative discharges that are being considered are to be discussed with the Medical Director, Counselor and the Clinical Director. The Medical Director approves or dispproves any administrative discharges. All patients are given the appeal process for any administrative discharges.
Timeframe for completion: Immediate
Person(s) Responsibel: Medical Director, Clinical Director, and Counselor |
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 narcotic treatment program failed to document short and long-term treatment goals in two of three patient records.
The findings include:
Twelve patient records were reviewed March 29-30, 2010. Treatment plans with realistic and measurable short and long-term treatment goals were required in three patient records. The narcotic treatment program did not document short and long-term goals that were written in a manner that could be measured for the patient's progress in patient records # 6 and 9.
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Plan of Correction
The Clinical Director will continue to provide weekly supervision for all clinical staff. The two charts in question have been reviewed with the respective counselors. Also, the City of Philadelphia, Integrated Monitoring Team, provides clinical documentation training for the Family Center staff. They have trained two counselors, to date, and will be continue this individualized training for the rest of the staff.
Timeframe for completion: Immediate in terms of addressing the documentation issues; within 3 months for the completion of the IMT training program for all staff; weekly supervision will continued with the counseling staff.
Person(s) responsible: Counselors and Clinical Director |
715.29(5) LICENSURE Exceptions
A narcotic treatment program is permitted, at the time of application or any time thereafter, to request an exception from a specific regulation.
(5) If the exception relates to a specific patient, the narcotic treatment program shall maintain documentation of the exception in the patient 's record.
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Observations
Based on a review of patient records and discussion with staff, the facility failed to document and/or submit the exception requests as required in three of three patient records. In addition, the facility failed to comply with the conditions of the exception granted by the Division regarding 13-day take-home privileges in 2 of 3 patient records.
The findings include:
Twelve patient records were reviewed March 29-30, 2010. Three patient records were reviewed for documentation pertaining to exception requests to not follow the regulations for take home medication.
The facility had written and submitted an exception request to the Division in September 2009 for patient # 7. The exception was approved for 13 day take home medication bottles. However, the documentation submitted to the Division did not contain all the relevant information needed to make an informed decision as to whether the request should be granted or not. The facility failed to include the patient's dose was split and therefore needed 27 bottles every 2 weeks. Also, the facility failed to include the information that the patient was also being prescribed opiates for her medical condition.
Patient # 8 was admitted May 18, 1988. The facility approved the patient for 13 take home medication bottles in may 2005. There was no Division exception form or approval in the patient's record.
Patients on thirteen day status based on the exception must have quarterly call backs (an unscheduled return to the facility within 24 hours) that includes an inventory of patient's remaining take home supply and drug testing or methadone plasma levels. The facility failed to conduct quarterly call backs for patients # 7 and 8. The quarterly call backs also require a review as to whether the reduced take-home schedule should continue. These reviews were not documented as part of the call backs that were completed.
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Plan of Correction
The request for the exception on #7 has been resubmitted for 13 THB's, but pick up is every week due to split dose. The rationale for the #7's RX for opiates has been narrated, approved by the Medical Director, and attached to the exception.
The request has been resubmitted for #8.
The Clinical Director will be maintaining a separate file for all approved State exceptions so that if documentation has been misfiled, there is a back-up system to support the exception has received State approval or denial.
The Clinical Director has met with the counselors for #7 & #8 and reviewed the quarterly call-back procedures. Also, quarterly call-backs will be discussed in weekly staff meetings using the Patient Profile list as a reference.
The prescription has been modified to include approval of the Medical Director for reduced THB schedules. This RX must be copied and attached to the quarterly call-back sheet.
Timeframe for completion: Immediate
Person(s) Responsible: Program Director, Clinical Director, Medical Director, and Counselor |