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 February 26-28, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Kensington Hospital Outpatient Treatment 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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715.9(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 clinical documentation, failed to document the basis for determining current and one year history of dependency in six of seven patient records.
The findings include:
Nineteen patient records were reviewed February 26-28, 2013. Seven patient records were reviewed for physician documentation of the basis for determining current and one year history of dependency.
Patient # 9 was admitted January 31, 2013. The only documentation by the physician for determining current dependency was the patient's statement. The determination for at least one year history of dependence was not documented in the patient record.
Patient # 10 was admitted November 15, 2012. The only documentation by the physician for determining at least one year history of dependence was not documented in the patient record.
Patient # 11 was admitted January 3, 2013. The only documentation by the physician for determining current dependency was the patient's statement. The determination for at least one year history of dependence was not documented in the patient record.
Patient # 12 was admitted October 4, 2012. The only documentation by the physician for determining dependence was the patient's statement.
Patient # 13 was admitted December 19, 2012. The only documentation by the physician for determining dependence was the patient's statement.
Patient # 14 was admitted January 5, 2013. The only documentation by the physician for determining dependence was the patient's statement.
Patient # 13 attended the facility as a guest doser from a narcotic treatment program from another state. The patient began guest dosing October 1, 2012. The physician wrote an initial order for the patient to guest dose for two weeks. The order was re-newed for an additional week. However, the patient continued to be dosed until the patient was "officially" admitted December 19, 2012. There was no documentation of a face to face meeting with the physician until February 21, 2013. This was discussed with the physician who acknowledged he did not meet with the patient until February 21, 2013 and that the order to dose the patient had expired in October 2012 and there was no order to dose until a new order was written February 21, 2013.
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Plan of Correction
The Physician was instructed to document the signs and symptoms of opiate drug use in determining current and one year history of dependency.
A monthly random chart review will be done by the Director of Behavioral Health Services to assure future compliance.
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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 three of three patient records reviewed.
The findings include:
Nineteen patient records were reviewed February 26-28, 2013. Three patient records required contacting the prior narcotic treatment facility for the previous treatment history the patient reported to have received.
Patient # 9, admitted January 31, 2013, contained documentation the patient had received narcotic treatment services previously at another narcotic treatment program. There was no documentation the facility made any attempt to contact the previous treatment provider for the patient's prior treatment history.
Patient # 10, admitted November 15, 2012, contained documentation the patient had received narcotic treatment services previously at another narcotic treatment program. There was no documentation the facility made any attempt to contact the previous treatment provider for the patient's prior treatment history.
Patient # 12, admitted October 4, 2012, contained documentation the patient had received narcotic treatment services previously at other narcotic treatment programs. There was no documentation the facility made any attempt to contact the previous treatment providers for the patient's prior treatment history.
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Plan of Correction
Clients seeking treatment in our MAT program will provide us with the necessary consents for release to prior MAT treatment episodes with MAT. It will be the Addictions Services Director who will monitor the program securing the necessary prior treatment histories. This was put in place after a staff meeting on 3-15-13. This process is necessary to provide continuity of care and look for patterns in not achieving goals set in recovery planning. |
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 a review of patient records, the facility failed to adhere to 4 Pa Code 255.5 and
709.28.
The findings include:
Nineteen patient records were reviewed February 26-28, 2013. Six patient records were reviewed specifically for confidentiality compliance.
Patient records # 9, 10, 11, 12, 13 and 14 each contained a consent that the only information checked to be released was the nature of the program. However, the patient's presence, admission and discharge dates were required by the receiver of the information.
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Plan of Correction
A meeting was held with staff to review Confidentiality protocol for completion of consents for Release of Information on 5/9/13. The Director of Behavioral Health will monitor by conducting monthly random chart reviews to assure future compliance. |
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 the review of patient records, the facility failed to ensure the narcotic treatment physician review the patient's dosage levels at least twice yearly in eight of eleven patient records reviewed.
The findings include:
Nineteen patient records were reviewed February 26-28, 2013. Eleven patient records required documentation of at least twice annual dose reviews. Eight of those patient records did not have the required twice annual dose reviews.
Patient # 2 was admitted in 1999. The last two dosage reviews completed were 12 months apart, January 12, 2012 and January 31, 2013.
Patient # 3 was admitted in 2004. The last two dosage reviews completed were more than 12 months apart, April 22, 2011 and February 11, 2013.
Patient # 4 was admitted in 2011. There was only one documented dose review dated February 26, 2013.
Patient # 5 was admitted in 2003. The last two dosage reviews completed were more than 12 months apart, November 30, 2010 and December 6, 2012.
Patient # 15 was admitted June 1, 2009. The last documented dose review was December 9, 2011.
Patient # 17 was admitted in 2010. There were no documented dose reviews.
Patient # 18 was admitted in 2010. There were no documented dose reviews.
Patient # 19 was admitted in 2011. There were no documented dose reviews.
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Plan of Correction
Each client in our MAT program will be scheduled for at least one annual assessment and two medication checks three times annually, four months apart. The Director of Addictions Services will oversee the scheduling of clients with their counselors to meet with the Addictions Services Medical Director to complete this standard. This process was discussed and designed at an Administrators' Meeting held on 3-21-13. It will be the duty of the administrative Assistant in Addictions Services to notify the clients and their couinselors when the apointments were scheduled for. |
715.16(a)(2) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(2) The narcotic treatment physician shall make this determination after consultations with staff involved in the patient's care.
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Observations
Based on a review of patient records, the facility failed to ensure the physician made take home determinations after consulting with the staff involved in the patient's care in four of seven patient records reviewed.
The findings include:
Nineteen patient records were reviewed February 26-28, 2013. Seven patient records were reviewed for take home medication procedures.
Patient # 1 was granted a third take home bottle August 30, 2012. There was no documentation of a consultation by the physician with the staff involved in the patient's treatment.
Patient # 2 was granted a sixth take home bottle. There was no documentation of a consultation by the physician with the staff involved in the patient's treatment.
Patient # 4 was granted a third take home bottle October 16, 2012. There was no documentation of a consultation by the physician with the staff involved in the patient's treatment.
Patient # 16 was granted a first take home bottle December 17, 2012. There was no documentation of a consultation by the physician with the staff involved in the patient's treatment.
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Plan of Correction
The clinical staff reviewed the revised protocol for the Take Home Policy on 5/9/13. The Director of Behavioral Health Services will conduct monthly chart reviews to assure future compliance. |
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 a review of patient records, the facility failed to ensure the physician documented the rationale for granting take home privileges in four of seven patient records reviewed.
The findings include:
Nineteen patient records were reviewed February 26-28, 2013. Seven patient records were reviewed for take home medication procedures and the documentation by the physician of the rationale for granting them..
Patient # 1 was granted a third take home bottle August 30, 2012. There was no documentation of the physician's rationale for granting the take home.
Patient # 2 was granted a sixth take home bottle. There was no documentation of the physician's rationale for granting the take home.
Patient # 4 was granted a third take home bottle October 16, 2012. There was no documentation of the physician's rationale for granting the take home.
Patient # 16 was granted a first take home bottle December 17, 2012. There was no documentation of the physician's rationale for granting the take home.
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Plan of Correction
The physician has been instructed to document the rationale for granting THB. It will be the responsibility of the Director of Behavioral Health Services to monitor future compliance by monthly random chart reviews. |
715.16(b)(1-8) LICENSURE Take-home privileges
(b) The narcotic treatment physician shall consider the following in determining whether, in exercising reasonable clinical judgment, a patient is responsible in handling narcotic drugs:
(1) Absence of recent abuse of drugs (narcotic or non-narcotic), including alcohol.
(2) Regular narcotic treatment program attendance.
(3) Absence of serious behavioral problems at the narcotic treatment program.
(4) Absence of known recent criminal activity.
(5) Stability of the patient 's home environment and social relationships.
(6) Length of time in comprehensive maintenance treatment.
(7) Assurance that take-home medication can be safely stored within the patient 's home.
(8) Whether the rehabilitative benefit to the patient derived from decreasing the frequency of attendance outweighs the potential risks of drug diversion.
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Observations
Based on a review of patient records, the facility failed to ensure the physician considered the eight points required for granting take home privileges in four of seven patient records reviewed.
The findings include:
Nineteen patient records were reviewed February 26-28, 2013. Seven patient records were reviewed for take home medication procedures and the consideration by the physician of the criteria required for granting them..
Patient # 1 was granted a third take home bottle August 30, 2012. There was no documentation the eight points were considered in determining the patient was responsible in handling narcotic drugs prior to the granting of the take home bottle.
Patient # 2 was granted a sixth take home bottle. There was no documentation the eight points were considered in determining the patient was responsible in handling narcotic drugs prior to the granting of the take home bottle.
Patient # 4 was granted a third take home bottle October 16, 2012. There was no documentation the eight points were considered in determining the patient was responsible in handling narcotic drugs prior to the granting of the take home bottle.
Patient # 16 was granted a first take home bottle December 17, 2012. There was no documentation the eight points were considered in determining the patient was responsible in handling narcotic drugs prior to the granting of the take home bottle.
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Plan of Correction
It is now the responsibility of the narcotic physician to determine eligibility for initial or additional take home bottles. He will also document the ratione utilizing the eight points of eligibility. The Director of Behavioral Health Services will monitor the compliance of this paperwork by conducting monthly random charts reviews.
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715.16(c)(1)(i-iv) LICENSURE Take-home privileges
(c) A narcotic treatment program shall require a patient to come to the narcotic treatment program for observation daily or at least 6 days a week for comprehensive maintenance treatment, unless a patient is permitted to receive take-home medication as follows:
(1) A narcotic treatment program may permit a patient to reduce attendance at the narcotic treatment program for observation to three times weekly and receive no more than a 2-day take-home supply of medication when, in the reasonable clinical judgment of the narcotic treatment physician, which is documented in the patient record:
(i) A patient demonstrates satisfactory adherence to narcotic treatment program rules for at least 3 months.
(ii) A patient demonstrates substantial progress in rehabilitation.
(iii) A patient demonstrates responsibility in handling narcotic drugs.
(iv) A patient demonstrates that rehabilitation progress would improve by decreasing the frequency of attendance for observation.
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Observations
Based on a review of patient records, the facility failed to ensure all patients demonstrated continued satisfactory adherence to the criteria for obtaining take home privileges in two patient records reviewed.
The findings include:
Nineteen patient records were reviewed February 26-28, 2013. Seven patient records were reviewed for continued compliance to the established criteria to obtain take home privileges. Two patient records contained documentation of recent illicit positive drug screens that were not addressed by staff, and the take home privileges continued.
Patient # 16 was admitted June 1, 2009. The patient was granted a take home bottle by the physician December 17, 2012, though the patient's urine drug screens were positive for illicit drugs for three of the last five months just prior to the take home request. The patient's urine drug screens were positive for illicit drugs August, September and November 2012.
Patient # 3 was admitted December 28, 2004 and has received take home privileges since 2011. The patient tested positive for benzodiazapine in February 2013. There was no documentation of the patient having a valid prescription for this substance.
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Plan of Correction
It has become the responsibility of the Director of Behavioral Health Director to monitor client progress on a monthly basis, group and individual session attendance, as well as. UDS results. This will be done using the new matrix for follow up for attendance and abstinence. |
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 five of eight patient records reviewed.
The findings include:
Nineteen patient records were reviewed February 26-28, 2013. Eight patient records were reviewed for case consultations.
Patient # 3 was due to have an annual case consultation by December 28, 2012. The case consultation was completed February 11, 2013, about six weeks late.
Patient # 6 was admitted January 10, 2005. While an annual case consultation was initiated, there was no documentation of a disposition or treatment team recommendations.
Patient # 10 was admitted November 15, 2012. A case consultation was to have been completed by February 15, 2013. There was no case consultation in the patient record at the time of the inspection.
Patient # 12 was admitted October 4, 2012. A case consultation was to have been completed by January 4, 2013. There was no case consultation in the patient record at the time of the inspection.
Patient # 16 was admitted June 1, 2009. An annual case consultation was due by June 1, 2012. The last documented case consultation was dated December 8, 2009.
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Plan of Correction
The Administrative Assistant will review all client start dates available on the matrix form and schedule clients due for annual assessments the following month. This will be done by the 15th of the preceding month and the scheduled appointments will be given to the counselors on the 16th of the month.
The Director of Behavioral Health Services will assure future compliance by monitoring this information on a weekly basis. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on a review of patient records, the facility failed to document all of the required information in three of three patient records.
The findings include:
Nineteen patient records were reviewed February 26-28, 2013. Three patient records were reviewed for complete discharge summaries.
Patient records # 17, 18 and 19 did not document a reason for entering treatment, the patient's response to the treatment process, services offered during the treatment stay and the condition of the patient upon discharge.
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Plan of Correction
All discharge summaries will be proofed before they are signed by the Director of Addictions Services to ensure that such areas as reason for entering treatment when they did are answered, as well as the condition of the patient when they are being discharged. We will also look for the patient's response to treatment throughout their stay at our MAT. No summaries will be signed until the paperwork has been looked over for these points along with other significant areas of questioning. |
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 two of two patient records reviewed.
The findings include:
Nineteen patient records were reviewed February 26-28, 2013. Two patient records required documentation of an attempt or completion of a follow up contact.
Patient # 18 was admitted July 21, 2010. The patient was discharged on November 12, 2012. The follow up contact documented was dated the same day patient was discharged.
Patient # 19 was admitted May 4, 2011. The patient was transferred to another narcotic treatment program October 2, 2012. The follow up documentation was dated September 7, 2012. The documentation dated September 7, 2012 stated the patient arrived for the appointment on September 24, 2012. Follow up is to be done within 7 days following the date of patient discharge.
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Plan of Correction
The follow up procedure has been revised to have the primary counselor of discharged client contact that client by mail for follow up information after 30 days. This process will also be repeated after 90 days. The Director of Behaivoral Health Services will monitor compliance by the counselor through a monthly random discharge audit.
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on the review of patient records, the facility failed to complete annual evaluations in accordance with the regulations in five of nine patient records reviewed.
The findings included:
Nineteen patient records were reviewed February 26-28, 2013. Nine patient records required documentation of an annual clinical review.
Patient # 1 was admitted March 8, 2011. An annual evaluation was due to be completed in March 2012. The annual evaluation was not completed until September 4, 2012.
Patient # 3 was admitted December 28, 2004. An annual evaluation was due to be completed in December 2012. The annual evaluation was not completed until February 11, 2013.
Patient # 6 was admitted January 10, 2005. An annual evaluation was due to be completed in January 2013. The last annual evaluation was completed in 2012.
Patient # 7 was admitted May 7, 2009. An annual evaluation was due to be completed in May 2012. There were no annual evaluations in the patient record at the time of the inspection.
Patient # 19 was admitted May 4, 2011. An annual evaluation was due to be completed in May 2012. There were no annual evaluations in the patient record at the time of the inspection.
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Plan of Correction
Staff was reminded at the staff meeting of 5/9/13 that it is required to closely monitor the client compliance with annual assessments. The Director of Behavioral Health Services will assure future compliance by a weekly review of the physician's/client contact sheet. |