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 12-14, 2012 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.
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Plan of Correction
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715.8(1)(vi) LICENSURE Psychosocial Staffing
A narcotic treatment program shall comply with the following staffing ratios as established in Chapter 704 (relating to staffing requirements for drug and alcohol treatment activities):
(vi) Outpatients. The counseling caseload for one FTE counselor in an outpatient narcotic treatment program may not exceed 35 active patients.
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Observations
Based on the review of administrative documentation and discussion with staff, the facility failed to maintain counselor caseloads to no more than 35 patients to 1 full time employee.
The findings include:
Administrative documentation that included counselor caseloads was reviewed and discussed on March 12, 2012.
Employee # 4 is employed part time (average 20 hours per week). According to the Narcotic Treatment Program Monitoring Questionnaire, the employee maintains a caseload of 23 patients. This calculates to a 43 to 1 ratio. The counselor himself reported working less hours per week, while administrative staff reported it was actually more. No further documentation was presented to support this counselor working more than the reported 20 hours per week.
The Narcotic Treatment Program Monitoring Questionnaire, completed by the facility,
reported 30 patients were currently not assigned to a counselor. Administrative staff acknowledged this information.
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Plan of Correction
Responsible Party: The Program Director is responsible for ensuring that the counselor to counselor ratio does not exceed 35:1 for FTE's.
The Program Director will ensure that Employee #4's caseload is decreased to ensure that he meets the 35:1 ratio. This will be completed by April 20, 2012.
The Program Director hired a full time counselor on 3/26/12 that all unassigned patients were assigned to.
Monitoring: Program Director and Intake Supervisor will monitor counselor to patient ratio during weekly supervision to ensure caseload sizes do not exceed 35:1.
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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 have the physician make a face to face determination and document the basis for determining current and one year history of dependency in six of six patient records reviewed.
The findings include:
Nineteen patient records were reviewed on March 12 to 14, 2012. Six patient records were reviewed for face to face documentation and physician documentation of the basis for determining current and one year history of dependency.
Patient # 13 was admitted on January 24, 2012. The first dose was administered on January 25, 2012. The patient was a transfer from another narcotic treatment program. The only documentation by the physician for determining at least one year history of dependence was the patient statement to the physician which was documented on February 1, 2012.
Patient # 14 was admitted on October 3, 2011. The first dose was administered on October 6, 2011. The patient was a transfer from another narcotic treatment program. The only documentation by the physician for determining at least one year history of dependence was the patient statement to the physician which was documented on October 13, 2011.
Patient # 17 was admitted on March 8, 2012. The patient record was missing documentation of a face to face assessment including documentation of current and one year history of dependency.
Patient # 18 was admitted on November 7, 2011. The first dose was administered on November 11, 2011. The only documentation by the physician for determining at least one year history of dependence was the patient statement to the physician.
Patient # 19 was admitted on February 3, 2012. The patient record was missing documentation of a face to face assessment including documentation of current and one year history of dependency.
Patient # 20 was admitted on February 27, 2012. The first dose was administered on February 29, 2012. The only documentation by the physician for determining at least one year history of dependence was the patient statement to the physician.
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Plan of Correction
Responsible Party: The narcotic treatment physician is responsible for determining at least a one year history of dependence.
The Medical Director will train all on site narcotic treatment physicians by 5/15/12 in relation to the determination of a patient's one year history of dependence utilizing additional criteria than patient's statement to the physician.
Monitoring: The Medical Director and Nursing Supervisor will review all admission and transfer in records to ensure that the one year history of dependence meets the criteria.
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715.9(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
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Observations
Based on the review of patient records, the facility failed to contact the previous narcotic treatment facility for the patient's treatment history in two of two patient records reviewed.
The findings include:
Nineteen patient records were reviewed March 12 to 14, 2012. Two patient records required contacting the prior narcotic treatment facility for the previous treatment history the patient reported to have received.
Patient # 18 was admitted on November 7, 2011. The patient record contained documentation the patient had received narcotic treatment services previously at another narcotic treatment program with no attempted contact.
Patient # 19 was admitted on February 3, 2012. The patient record contained documentation the patient had received narcotic treatment services previously at another narcotic treatment program with no attempted contact.
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Plan of Correction
Responsible Party: The Intake Worker and Intake Supervisor are responsible for contacting prior NTP's for previous treatment history of patient's being enrollled into the program.
The Intake Supervisor will review patient records #18 and #19 to identify previous NTP enrollment. Intake Worker will contact previous NTP for each patient and attempt to get prior treatment history, with patient consent. This will be completed by 5/15/12. Intake staff will be trained by Program Director by 4/27/12 on obtaining previous NTP treatment history.
Monitoring: The intake supervisor will review all new patient admission records to ensure that previous treatment history attempts are documented. |
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 direct observation and on the review of patient records, the facility failed to physically secure and maintain the confidentiality in six of six patient records.
The findings include:
Observation of the facility and review of nineteen patient records occurred on March 12 to 14, 2012. Six patient records were reviewed for documentation of consent to release information.
Patient records reviewed were maintained in a closed desk drawer in a locked office not used by current staff. A patient record was found in the desk drawer when the records were retrieved on March 13, 2012. This record had not been requested for review. The facility failed to secure the patient record in a locked, limited access storage container as required by regulation.
Group room doors were kept open during morning group on March 14, 2012.
Patient # 13 was admitted on January 24, 2012. A consent to release information permitted the release of "reason in treatment" to transportation and probation. The reason in treatment was not specific and was therefore not within the requirements for specific information to be released. This information exceeds the parameters of 4 Pa. Code 255.5.
Patient # 14 was readmitted on November 30, 2011. A consent to release information permitted the release of "reason in treatment" to probation. The reason in treatment was not specific and was therefore not within the requirements for specific information to be released. This information exceeds the parameters of 4 Pa. Code 255.5.
Patient # 17 was admitted on March 8, 2012. A consent to release information permitted the release of "reason in treatment" to funding source and probation. The reason in treatment was not specific and was therefore not within the requirements for specific information to be released. This information exceeds the parameters of 4 Pa. Code 255.5.
Patient # 18 was admitted on November 7, 2011. A consent to release information permitted the release of "reason in treatment" to transportation, funding source and probation. The reason in treatment was not specific and was therefore not within the requirements for specific information to be released. This information exceeds the parameters of 4 Pa. Code 255.5.
Patient # 19 was admitted on February 3, 2012. A consent to release information permitted the release of "reason in treatment" to funding source and probation. The reason in treatment was not specific and was therefore not within the requirements for specific information to be released. This information exceeds the parameters of 4 Pa. Code 255.5.
Patient # 20 was admitted on February 27, 2012. A consent to release information permitted the release of "reason in treatment" to transportation, funding source and probation. The reason in treatment was not specific and was therefore not within the requirements for specific information to be released. This information exceeds the parameters of 4 Pa. Code 255.5.
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Plan of Correction
Responsible Party: The Program Director, Clinical Staff and Intake Staff are responsible for ensuring the consents to release information are completed accurately and placed in the patient record, in a locked area.
The Program Director will remove all documentation found in the closed desk drawer by 4/18/12 and place in the medical records area for filing into the corresponding patient records.
Staff will be trained on the proper filing of documentation and completion of consents to release information by 5/15/12.
The Program Director will also train all staff in relation to facilitating confidential services behind a closed door by 5/15/12.
All consents to release information for charts 13,14,17,18,19 and 20, that did not meet the standard will be updated by 4/27/12 to ensure all elements are completely and accuarately completed.
Monitoring: Intake Supervisors and Clinical Supervisors will review random sample of counselor records on a monthly basis to ensure consents to release information are completely correctly. |
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 an initial drug-screening analysis and random urinalysis at least monthly for seven of seven patient records reviewed.
The findings include:
Nineteen patient records were reviewed on March 12 to 14, 2012. Seven patient records were reviewed for drug-screening urinalysis.
Patient record # 5 last documented drug-screening urinalysis occurred in December 2008.
Patient # 6 was admitted on June 21, 2011. The last documentation of drug-screening urinalysis occurred on January 19, 2012.
Patient # 13 was admitted on January 24, 2012. The last documentation of drug-screening urinalysis occurred on January 26, 2012.
Patient # 17 was admitted on March 8, 2012. The record had no documentation of an initial drug-screening urinalysis.
Patient # 18 was admitted on November 7, 2011. The last documentation of drug-screening urinalysis occurred on October 31, 2011. The patient's first dose was on November 11, 2011. This occurred 12 days after the drug-screening urinalysis.
Patient # 19 was admitted on February 3, 2012. The record had no documentation of an initial drug-screening urinalysis.
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Plan of Correction
Responsible Party: The Nursing/Medical Dept are responsible for ensuring that all patients are administered at least one drug screen per month, and upon admission. The medical records dept is responsible for ensuring timely filing of urinalysis reports in the patient record.
The Nursing Supervisor will schedule all new admissions, referring into the program, for a urinalysis within 3 days of admission onto program, and regular patients for at least one drug screen per month.
Monitoring: The Medical Records Supervisor will review status of filing on a weekly basis to ensure that all urinalysis reports are filed into the patient record in a timely manner, upon reciept from the laboratory. |
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 documented the exception circumstance in one of one patient record reviewed.
The findings include:
Nineteen patient records were reviewed on March 12 to 14, 2012. One patient record required an exception circumstance take home medication request.
Patient # 10 was admitted on 10/21/2009. The documentation identified reduced clinic attendance with 6 take home bottles due to multiple medical issues. The patient did not meet the criteria for 6 take home medication bottles which includes 3 years of program attendance. The patient was given the reduced clinic attendance without having the physician documentation of the clinical judgment, or document the reduced schedule as an exception.
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Plan of Correction
Responsible Party: The Medical Director and Narcotic Treatment Physicians are responsible for ensuring that all patients who recieve take home bottles and do not meet state criteria, have an exception filed with the state.
The Medical Director/NTP physician, will review patient record #10. If patient is assessed as being still in need of take home bottles, an exception will completed and forwarded to the state by 5/4/12. Medical, Nursing and Clinical Staff will be trained on the take home exception regulation by 5/2/12
Monitoring: The Nursing Supervisor will review all take home bottle requests to identify whether or not a state exception is needed. If necessary, the Nursing Supervisor will alert the Medical Director to ensure the exception is filed. |
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 documented the patient's initial and subsequent dose in seven of fifteen patient records reviewed.
The findings include:
Nineteen patient records were reviewed on March 12 to 14, 2012. Fifteen patient records were reviewed for documentation of patient's initial and subsequent doses.
Patient record # 1 had no documentation of medical records.
Patient record # 5 had no documentation of medical records.
Patient # 8 was admitted on August 19, 2008. The physician orders documented on January 4, 2012, stated the date of the order, the dose, the comment "involuntary termination" and the last dose of January 23, 2012. The order did not provide a breakdown of the change in dose from January 4 to 23, 2012.
Patient # 12 was admitted on November 12, 2010. The physician orders documented on November 7, 2011, stated the date of the order, the dose, the comment "involuntary termination due to selling drugs" with an end date of November 30, 2011. The order did not provide a breakdown of the change in dose from November 7 to 30, 2011.
Patient # 15 was admitted in September 2010. The physician orders documented a reduction in dose on 9/21/2011, however, the order was not signed.
Patient # 17 was admitted on March 8, 2012. The patient record had no documentation of physician orders.
Patient # 18 was admitted on November 7, 2011. The patient was dosed on November 11, 2011. The physician order for the initial dose was written on November 14, 2011. A physician order for an increase in dose was written on the same date.
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Plan of Correction
Responsible Party: The Medical Director and Narcotic Treatment Physicians are responsible for ensuring that all initial and subsequent dose orders are clearly documented and signed by the prescribing physician within 24 hours.
The Medical Director will review patient records #1,5,8,12,15,17 and 18 and correct each order,where possible by 4/27/12.
The Medical Director will train the Narcotic Treatment Physicians in the accurate completion of orders by 5/15/12.
Monitoring: The Nursing Supervisor will review all orders completed by the physicians to ensure that they are accurately completed and signed off by the prescribing physician. All orders that do not meet the standard, will be returned to the physician for correction. |
715.17(c)(7) 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:
(7) Drug reactions and medication errors. A narcotic treatment program shall report any adverse drug reaction or medication error to a narcotic treatment physician immediately and initiate corrective action. The narcotic treatment program shall record the reaction or error in the drug administration record and the clinical chart, and shall inform each person who is authorized to administer medication or supervise self-medication of the reaction or error.
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Observations
Based on the review of patient records, the facility failed to ensure documentation and reporting of medication errors.
The findings include:
Nineteen patient records were reviewed on March 12 to 14, 2012. One patient record was found to have a documented medication error, # 18.
Patient # 18 was admitted on November 7, 2011. The patient was dosed on November 11, 2011. The physician order for the initial dose was written on November 14, 2011, for 30 mg. A physician order for an increase in dose to 45 mg was written on November 14, 2011. The patient was given 30 mg and an additional 45 mg on November 14, 2011. No documentation was found in the patient record that the administering nurse reported this error to the physician within 24 hours as is required by the facility policy.
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Plan of Correction
Responsible Party: The Nursing Supervisor is responsible for the documentation of all medication errors and adjustments.
The documentation for medication adjustment/error for record #18 was located in the exceptions binder housed in the Nursing office, but was not presented to the reviewers at the time of the inspection.
Monitoring: The Nursing Supervisor will maintain the exceptions binder in the nursing office that documents all medication errors and exceptions in dosing. Program Director will review weekly to ensure that all excpetions are documented and reported where necessary. |
715.18(b) LICENSURE Rehabilitative services
(b) A patient shall also have the opportunity to access legal services.
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Observations
Based on the review of administrative documentation and patient records, the facility failed to demonstrate that legal services could be made available to patients as needed.
The findings include:
Administrative documentation that included referral agreements and nineteen patient records were reviewed on March 12 to 14, 2012.
Facility referral agreements did not include a provider of legal services.
Nineteen patient records were reviewed and did not include a referral for legal services.
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Plan of Correction
Responsible Party: The Program Director is responsible for ensuring an active referral agreement for legal services.
The Program Director will obtain a signed referral agreement with an external legal services entity, which will be maintained in a binder with all other active referral agreements. This will be completed and signed by 5/15/12.
Monitoring: The Program Director will review all referral agreements monthly to ensure that they are current. |
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 the review of patient records, the facility failed to transfer the required patient files in three of five patient records reviewed.
The findings include:
Nineteen patient records were reviewed March 12 to 14, 2012. Five patient records required the facility transfer specific patient files to the receiving narcotic treatment program as part of the transfer process. Three patient records did not transfer the specified files.
Patient # 1 was discharged as a transfer to another narcotic treatment facility. The patient record documented the counselor was transferring patient to another narcotic treatment facility. There was no documentation the required patient files were transferred to the receiving facility.
Patient # 11 was discharged as a transfer to another narcotic treatment facility on December 29, 2011. The patient record documented an individual session where the patient requested a transfer on November 15, 2011. The patient record included a consent to release information for transfer to another narcotic treatment facility dated the same date. There was no documentation the required patient files were transferred to the receiving facility.
Patient # 12 was discharged as a transfer to another narcotic treatment facility November 23, 2011. The patient record documented a session note on November 14, 2011, stating the patient had an appointment for transfer on November 15, 2011. There was no documentation the required patient files were transferred to the receiving facility.
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Plan of Correction
Responsible Party: The Clinical Medical Records and Counseling Staff are responsible for ensuring that all required documents are sent to the recieving facility for all transfers from the program.
The Counseling and Medical Records staff will be trained by the Program Director by 5/15/12 in relation to all documents that must be sent to the recieving faciity for all transfers.
Monitoring: The Clinical Supervisors and Medical Records Supervisor will review all transfer documentation prior to sending it to the recieving facility to ensure that all documentation is appropriate, and evidence of what documentation was sent is also identified. |
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 the review of patient records, the facility failed to transfer the required patient files in three of five patient records reviewed.
The findings include:
Nineteen patient records were reviewed March 12 to 14, 2012. Five patient records required documentation of the materials sent to the receiving narcotic treatment program. Two patient records did not document what materials were sent.
Patient # 1 was discharged as a transfer to another narcotic treatment facility. The patient record documented the counselor was transferring the patient to another narcotic treatment facility. There was no documentation what patient files were sent to the receiving facility.
Patient # 11 was discharged as a transfer to another narcotic treatment facility on December 29, 2011. The patient record documented the counselor was transferring patient to another narcotic treatment facility. There was no documentation what patient files were sent to the receiving facility.
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Plan of Correction
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.
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 5/15/12.
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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715.23(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, the facility failed to maintain complete and updated records in seven of nineteen patient records reviewed.
The findings include:
Nineteen patient records were reviewed March 12 to 14, 2012, and required to have complete and current information.
Patient record # 1 did not contain any documentation other than clinical notes of individual and group sessions.
Patient record # 5 had documentation of the most recent drug-screening analysis dated December 2008 and case consult dated February 27, 2007. This record had no medical documentation.
Patient # 6 was admitted on June 21, 2011. This record had documentation of the most recent treatment plan on December 2, 2011, case consultation on September 17, 2011, a record of service until July 28, 2011 and the most recent progress note of January 23, 2012.
Patient # 17 was admitted on March 8, 2012. The documentation in this record included the admission date, patient identification and documentation from the transferring facility. There were no further documents.
Patient # 18 was admitted on November 7, 2011. The documentation in this record failed to include drug-screening analysis. The most recent progress note was of December 27, 2011.
Patient # 19 was admitted on February 3, 2012. The documentation in this record failed to include a psychosocial evaluation and comprehensive treatment plan.
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Plan of Correction
Responsible Party: The Clinical Supervisors, Counseling Staff and Medical Records staff are responsible for maintaining a complete file on site for each present and former patient of the NTP.
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 5/15/12.
Medical Records staff will recieve training and documented supervision regarding the timelines for filing current documentation in the patient record by4/27/12.
Records:#1 will be brought current by 4/27/12.
Records # 5 will have all current documentation completed and filed by 4/27/12.
Records # 6 will be have updated treatment plan, case consulation, records of service and progress notes completed and filed in the record by 5/15/12.
Record # 17 will have all documentation completed and filed in record by 5/15/12.
Record# 18 will have all drug screening analysis filed in the record and progress notes completed and filed in the record by 5/15/12.
Record # 19 will have bio psycho social and evaluation and comprehensive treatment plan completed and filed by 5/15/12.
Monitoring: Clinical Supervisors will review document submission to ensure all documents are completed as required. Medical Records Supervisor will review status of medical records filing on a weekly basis to ensure timey filing of documents. |
715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on the review of patient records, the facility failed to ensure the physician documented the results of an initial intake physical examination in three of five records reviewed.
The findings include:
Nineteen patient records were reviewed March 12 to 14, 2012. Five records were reviewed for documentation of an initial physical examination.
Patient # 13 was admitted on January 24, 2012. A medical note form dated January 25, 2012, stated the history and physical were reviewed from the prior provider. No documentation was noted on the previous provider's history and physical exam form citing review or update by the physician. A physical examination was not documented upon the patient's admission to the program.
Patient # 17 was admitted on March 8, 2012. A physical examination was not documented upon the patient's admission to the program.
Patient # 19 was admitted on February 3, 2012. A medical note form dated February 6, 2012, stated the history and physical were reviewed from the prior provider. No documentation was noted on the previous provider's history and physical exam form citing review or update by the physician. A physical examination was not documented upon the patient's admission to the program.
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Plan of Correction
Responsible Party: The Narcotic Treatment Physician and Medical Director are responsible for ensuring that a review of the physical exam from a referring facility is reviewed and documented and that the initial physicial exam is completed.
Record #13 will be updated to cite the doctor's review of the referring facility's exam (on the previous providers exam) by 4/27/12
Record #17 will have an updated physical and exam completed and documented by 4/27/12.
Record #19 will be updated to cite the doctor's review of the referring facility's exam (on the previous providers exam) by 4/27/12.
The Medical Director will train NTP by 4/20/12 on the correct documentation of the review of the initial exam from the referring agency.
Monitoring: The Nursing Supervisor will ensure weekly review of all admissions to ensure inital exam and documentation of review of previous provider's exam are documented properly.
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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 ensure the patient record included a record of services provided to the patient in nine of nine records reviewed.
The findings include:
Nineteen patient records were reviewed March 12 to 14, 2012. Nine records were reviewed for documentation of the patient record of service.
Patient record # 1 had no documentation of the record of service in the patient record.
Patient record # 5 had no documentation of the record of service in the patient record.
Patient # 6 was admitted on June 21, 2011. The record had documentation of a record of service that ended on July 28, 2011. The patient was active in treatment as of the date of the inspection.
Patient # 7 was admitted on November 15, 2010, and discharged on November 14, 2011. The record had documentation of a record of service that ended in August, 2011.
Patient # 8 was admitted on August 19, 2008, and discharged on January 24, 2012. The record had no documentation of a record of service in the patient record. Clinical notes for services continued to November 14, 2011.
Patient # 9 was admitted on June 10, 2005, and discharged on November 22, 2011. The record had documentation of a record of service that ended on July 28, 2011. Clinical notes for services continued to October 4, 2011.
Patient # 10 was admitted on October 21, 2009, and discharged on February, 26, 2012. The record had documentation of a record of service that ended on July 28, 2011. Clinical notes for services continued to January 24, 2012.
Patient # 12 was admitted on November 12, 2010, and discharged on November 23, 2011. The record had documentation of a record of service that ended on July 28, 2011. Clinical notes for services continued to November 14, 2011.
Patient # 13 was admitted on January 25, 2012. Patient record had no documentation of the record of service in the patient record.
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Plan of Correction
Responsible Party: The billing department is responsible for running all records of service on a monthly basis. The Medical Records Dept is responsible for ensuring timely filing of the monthly records of service.
Records 1,5,6,7,8,9,10,12 and 13 will have all necessary records of service run and filed into the corresponding patient record by 5/15/12.
Monitoring: The Program Director will ensure that all monthly records of service are run for the program by the end of the first week of the following month.
The Medical Records Supervisor will review status of Medical records filing on a weekly basis to ensure timely filing of all monthly records of service. |
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 three of four patient records reviewed.
The findings include:
Nineteen patient records were reviewed March 12-14, 2012. Four patient records were reviewed for case consultations.
Patient record # 5 had documentation of a case consultation on February 27, 2007. Case consultations are required annually following the first year of treatment.
Patient # 6 was admitted on June 21, 2011. A case consultation was documented on September 17, 2011. No further case consultations were documented at the time of the review.
Patient # 7 was admitted on November 15, 2010, and discharged on November 14, 2011. A case consultation was documented on May 10, 2011. No further case consultations were documented at the time of the review.
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Plan of Correction
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.
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, 2012.
Records 5,6 and 7 will have an updated case consultation completed by 4/27/12.
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.
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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 or completed within the policy-stated 30 days of admission.
The findings include:
Nineteen patient records were reviewed March 12-14, 2012. Three patient records were reviewed for psychosocial evaluations. Two patient records did not have the required psychosocial evaluation as required.
Patient # 13 was admitted January 25, 2012. An evaluation was to have been completed by February 24, 2012, but had not been completed at the time of the inspection.
Patient # 19 was admitted February 3, 2012. An evaluation was to have been completed by March 4, 2012, but had not been completed at the time of the inspection.
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Plan of Correction
Responsible Party(s):
Counseling 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 May 15, 2012.
Records #13 and 19 will have an updated biopsycho social evaluation completed by 4/27/12.
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, the facility failed to document all of the required information and within seven days of discharge in nine of twelve patient records.
The findings include:
Nineteen patient records were reviewed March 12-14, 2012. Twelve patient records were reviewed for complete and timely discharge summaries.
Patient record # 1 was provided to the reviewers as a discharged patient. The only components of the record provided were the counselor notes. On December 19, 2011, there was a clinical note discussing the counselor transferring the patient to another state. There was no discharge summary in the patient record at the time of the inspection.
Patient # 2 was admitted May 25, 2011 and discharged to another narcotic treatment facility October 9, 2011. The discharge summary was documented October 17, 2011 and did not contain information on patient's response to treatment.
Patient # 7 was admitted November 15, 2010. The patient was listed on the discharge list provided by the facility as discharged on November 14, 2011. However, the patient had been transferred to another narcotic treatment facility as of September 20, 2011. The receiving facility was notified of patient's last dose at this facility as being on August 19, 2011. The discharge summary failed to document the reason for admission and a response to treatment.
Patient # 9 was admitted June 10, 2005. The patient was discharged as deceased November 22, 2011. There was no documentation of a reason for treatment, response to treatment and not all required components of a medication assisted treatment program were identified as services offered to the patient during the treatment episode.
Patient # 10 was admitted October 21, 2009. The patient was discharged as deceased February 26, 2012. There was no documentation of all required components of a medication assisted treatment program as being offered to the patient during the treatment episode.
Patient # 11 was admitted October 6, 2010. The patient was discharged December 29, 2011. The patient's status or condition at discharge was not identified.
Patient # 12 was admitted November 12, 2010. The patient was discharged November 23, 2011. The patient's status or condition at discharge was not identified.
Patient # 14 was admitted October 3, 2010. The patient was discharged December 8, 2011. The reason for the patient entering treatment was not documented. There was no documentation of the patient's response to treatment. The patient's status or condition at discharge was not identified.
Patient # 15 was admitted September 2010 and discharged as deceased November 15, 2011. There was no documentation of all required components of a medication assisted treatment program as being offered to the patient during the treatment episode.
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Plan of Correction
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.
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, 2012.
Records 1,2,7,9,10,11,12,14 and 15 will have complete discharges and corresponding documentation completed and filed in the clinical record by 5/15/12.
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 six of six patient records reviewed. Referred patients are required to have this attempted contact within seven days of the appointment with the receiving facility.
The findings include:
Nineteen patient records were reviewed June 3, 2011. Six patient records were reviewed for documentation of an attempt or completion of a follow up contact.
Patient # 2 was admitted May 25, 2011 and transferred to another narcotic treatment facility October 9, 2011. There was no documentation of any follow up to confirm the patient kept the appointment with the receiving narcotic treatment facility.
Patient # 11 was admitted October 6, 2010 and transferred to another narcotic treatment facility December 29, 2011. There was no documentation of any follow up to confirm the patient kept the appointment with the receiving narcotic treatment facility.
Patient # 12 was admitted November 12, 2010. The patient was discharged November 23, 2011. There was no documentation a follow up contact had been attempted at the time of the inspection.
Patient # 14 was admitted October 3, 2011 and re-instated after incarceration November 30, 2011. The patient was discharged December 8, 2011 as absent without leave. There was no documentation a follow up contact had been attempted at the time of the inspection.
In discussion with a staff person to explore how follow up contacts were documented, the staff person reported that follow up contacts were not conducted.
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Plan of Correction
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.
The Facility Director and Clinical Supervisors will train the Clinical Counseling staff regarding the documentation of follow up information in the patient record by May 15, 2012.
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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