INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use a narcotic agents methadone and buprenorphine in the treatment of narcotic addiction. This inspection was conducted on May 20, 21, and 22, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Aldie Foundation, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on June 19, 2008.
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Plan of Correction
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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
A review of 12 patient records that included a specific review of six records for physician documentation, patient record #3 failed to include the physician's documentation of the basis for determining current and one year history of addiction. Also, the documentation of the admission urine drug screen was negative for opiates, hence the basis for current dependency is unknown.
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Plan of Correction
Narcotic Treatment Physician will fully evaluate, prior to admission, all clients and all documentation on every candidate presenting for admission to the Pharmacotherapy Program to determine current and at least one
year history of addiction
The narcotic treatment Physician's determination will be documented and placed in the client's record along with his physical examination paperwork. The physical examination will note current specific withdrawal symptoms. A positive urine drug screen at admission can be used as part of this documentation, but will not be the only basis for determining dependency. The Program Coordinator will review all new admission records weekly to assure this process is followed consistently.
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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
Of the 12 patient records reviewed, one record was reviewed for contact with the patient's previous narcotic treatment program. The facility failed to, with patient consent, contact the previous narcotic treatment facility for the patient's treatment history for patient # 2.
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Plan of Correction
A procedure is in place for previous narcotic treatment programs to be contacted at the time of admission. The Assessment Coordinator will train the assessment staff regarding this procedure. The Pharmacotherapy Coordinator will, in turn, be responsible to review the "Assessment QA Chart Review" form to determine completion of the "Pre Admit Records Request". Final completion of the Records Request will be the responsibility of the Pharmacotherapy Coordinator prior to intake. Documentation of this process will appear in the orientation progress note. The Coordinator will maintain oversight and compliance with this process. |
715.10(b) LICENSURE Pregnant patients
(b) A narcotic treatment program shall give pregnant patients the opportunity for prenatal care either by the narcotic treatment program or by referral to appropriate health-care providers.
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Observations
A review of 12 patient records revealed that the facility failed to document in one of three records that were applicable for this regulation that the patient received any prenatal care, patient record # 2.
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Plan of Correction
A questionnaire/checklist form will be implemented with all pregnant client admissions as well as any client who becomes pregnant while in treatment. It shall include; current prenatal care being received and by whom, possible referral(s) for prenatal care and agencies referred to, and prenatal care provided by Aldie. This questionnaire will be completed at orientation, or at any time later in treatment when applicable, by the Program Coordinator, signed and dated by them and the client and provided to the primary therapist assigned for ongoing oversight, review and updates. Process to begin 6/30/08. Consents/Releases of Information will be obtained from the client at time of Intake, specific to any OB/GYN, Pediatrician, or prenatal care service provider. The primary therapist will make regular monthly contact with any of these professionals to ascertain the clients continued involvement in prenatal care services, these contacts will be documented in client record, in the progress note section of the record and/or as a Special Case Consult. This process will begin 7/10/08 and will be ongoing. The Program Coordinator will review the client records during routine quarterly QA review to assure proper documentation of prenatal services to all clients identified as pregnant both at admission as well as during the course of treatment. |
715.10(c) LICENSURE Pregnant patients
(c) Counseling records and other appropriate patients records shall reflect the nature of prenatal support provided by the narcotic treatment program.
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Observations
A review of 12 patient records revealed that in one of three applicable records the facility failed to include documentation that the patient received any prenatal support by the facility, patient record # 2.
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Plan of Correction
A questionnaire/checklist form will be implemented with all pregnant client admissions.as well as any client who becomes pregnant during the course of treatment It shall include; current prenatal care being received and by whom, possible referral(s) for prenatal care and agencies referred to, and prenatal care provided by Aldie. This questionnaire will be completed at orientation, or at any time later in treatment, when applicable, by the Program Coordinator, signed and dated by them and the client and provided to the primary therapist assigned for ongoing oversight, review and updates. Process to begin 6/30/08. Any/All prenatal services provided by Aldie, to the client, will be documented by the assigned service provider, either in the form of an individual progress note or in the form of a group progress note, dependent on the type of service provided. The progress note will then be filed in the appropriate section of the client record. The Program Coordinator will review client record during routine quarterly QA record review to assure documentation of prenatal care services provided by Aldie, is present in all pregnant client records. to all clients identified as pregnant both at admission as well as subsequent to admission during the course of treatment. Process to begin 7/10/08 and will be ongoing. |
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
A review of 12 patient records revealed that the facility failed to ensure the completion of random monthly urine drug screens in one of seven applicable records, specifically patient # 8 did not have a drug screen done in March 2008.
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Plan of Correction
Currently random urine drug screens are initiated electronically. The AMS system includes a check box feature that insures scheduling of randomly selected urines. Moving forward, the Nurse Manager will run a weekly report prior to the weekly run of the urine test labels to cross check against this feature to determine that all clients have been assigned to a urine screen schedule. |
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
A review of 12 patient records revealed that the facility failed to include the physician's rationale for permitting take home medication in one of three patient records reviewed for take home requests, specifically record # 5. In addition, the clinical record documentation did not support granting take home privileges. This recommendation changed on the actual day the request was presented to the treatment team, however, the record contained no documentation to justify or support this change from the counselor's prior lack of support.
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Plan of Correction
Narcotic treatment physician will document on every take-home form, their rationale for permitting that take-home medication. A case consult will be conducted with each take-home request, to include; comments and/or concerns from each team member present (including physician) regarding clients eligibility for requested take-home medication. The Program Coordinator will review each take-home request form and each case consult for substance and completeness before signing off on either form. Procedure began on 6/5/08. |
715.16(a)(5) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(5) A narcotic treatment program shall develop written policies and procedures relating to granting and rescinding take-home medication privileges.
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Observations
Based on the review of the facility policy and procedure manual, the facility exceeded what is permitted by regulation by stating emergency take home medications may be given without meeting other requirements as long as the emergency is "well-documented".
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Plan of Correction
Written policy and procedure was changed by the Quality Assurance officer to reflect that the consideration of emergency take home medications does not preclude assurance that State and Federal requirements are met. The pharmacotherapy Coordinator will provide training to the clinical staff regarding the policy change and provide oversight to assure adherence. |
715.20(4) 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.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
A review of 12 patient records revealed that two of two applicable records failed to include documentation of the facility having notified the transferring facilities of the acceptance and initial dosing of patients #1 and 8.
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Plan of Correction
The Program Coordinator will assure that all facilities referring clients for methadone treatment services be sent written notification of client accepted into treatment and the date of initial dose of methadone. Transfer confirmation form will be faxed by nurse upon arrival and dosing of referred client. This form will then be forwarded to the Program Coordinator who will note completion on the orientation checklist form. |
715.21(1)(i-iv) 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.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
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Observations
Based on the review of the policy and procedure manual and chart documentation of an orientation form signed by patients, the facility failed to restrict the policy and procedure on patient termination to the reasons permitted by regulation. The facility documentation stated that a second falsification of urine drug screen is a reason for an administrative (involuntary) detoxification.
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Plan of Correction
Written Policy and Procedure was changed by the Quality Assurance Officer to reflect the Federal and State regulatory limitations for involuntary termination. Policy regarding falsification of urine drug testing will now reflect behavioral and treatment sanctions excluding involuntary termination.
The Pharmacotherapy Coordinator will provide training to the clinical staff on the policy change and ensure oversight that the policy is adhered to.
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715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
A review of 12 patient records revealed that the facility failed to document that a tuberculosis Mantoux test was completed for three of eight applicable patients that were reviewed. Record # 3 did not have documentation of a Mantoux test; # 5 did not have a date that the test results were read, and # 8 contained documentation that the test was conducted at another facility and the results were forwarded by the transferring program, but there was no documentation of the test or the results.
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Plan of Correction
Aldie will conduct a Mantoux TB test on all clients admitted to the Pharmacotherapy Program rather than relying on receipt of test results from other agencies. The Nurse Manager will then file a copy of all mantoux tests conducted in a log locked in the dispensary. The Nurse Manager and the Program Coordinator will review client records quarterly to assure each client record contains a completed Mantoux test with the following properly recorded; date test was administered, by whom, results of the test, and notification of physician in cases where tests results were positive. |
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
A review of 12 patient records revealed that two of five evaluations were missing (records # 2 & 8), and # 4 failed to contain an evaluative assessment of the historical data obtained that included the counselor's clinical analysis of the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, patient's attitude toward treatment and overall impressions. Instead, the psychosocial evaluation of the patient consisted primarily of the repetition of the history and statements reported by the patient.
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Plan of Correction
The Program Coordinator will provide training, ongoing quality review, and supervision regarding the need to synthesize factual information gathered in intake into a clinical evaluation of assets/strengths/support systems and coping mechanisms etc., as well as the required time frames for completion of this document. Specific attention will be paid to the assessment of clinical data. This clinical assessment will be reviewed by the Program Coordinator for content quality and legibility before being cosigned and placed in the client's chart. In addition, concurrent peer chart review will be conducted monthly with a random sampling of currently active client records. The Program Coordinator will train all Pharmacotherapy Counselors, specific to this deficiency, by 7/17/08. Chart review and supervision of counselors, specific to this deficiency, will be ongoing, and at a minimum, quarterly, to assure the deficiency is corrected and remains corrected. |
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
A review of 12 patient records revealed that the facility failed to develop treatment plans that contained measurable steps. Three of five applicable patient records reviewed, patient records # 2, 4, and 8 contained vague, non-specific steps to reach the gaols and the time frames were generalized rather than realistically specific to the action step. Further, the treatment plans failed to identify support services needed by the patient.
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Plan of Correction
The Program Coordinator will provide an in-service to all Pharmacotherapy Counselors on proper Treatment Plan development. The in-service will include; how to write specific, easy to understand steps to reach the identified goals, the identification and incorporation of external supports, and how to individualize time frames for completion of those steps (objectives). In-service to take place in group supervision scheduled 6/11/08. The Program Coordinator will continue to maintain quarterly review of clinical records for completeness specific to this corrective action plan. In addition, concurrent peer chart review will be conducted monthly with a random sampling of currently active client records.
The agency is also about to embark on a year-long training program and research collaboration with TRI (Treatment Research Institute) with focusing on improvement in the quality and effectiveness of treatment plans. The program will focus on identification of observable measurable goals with specific links to supports for identified problem areas. Clinicians will be receiving 8 hours of CAC training from TRI specific to this initiative.
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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
A review of 12 patient records revealed that the facility failed to file an exception request with the Department for patient # 5 prior to ordering vacation take home medication bottles before the patient was eligible for take home bottles.
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Plan of Correction
All clinical staff will be trained on the policy and procedures for requesting exceptions. The Program Coordinator will assure all take-home medication exception requests, requiring Department approval, are filed with the Department. Clients not eligible for take-homes will not be granted take-home medication until Department approval has been obtained. It will be the responsibility of the Program Coordinator to review all take-home exception requests with the program physician, forward those requests to the Department, serve as contact person for all requests, and receive all Department responses on requests. The Program Coordinator will report back to the Treatment Team the status of forwarded exception requests. This practice was put into effect immediately 5/23/08. |