INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use narcotic agents, specifically methadone and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on April 14, 15, 16 and 17, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Parkside Recovery 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 May 16, 2008.
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Plan of Correction
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715.6(a)(3)(ii) LICENSURE Physician staffing
(a) A narcotic treatment program shall designate a medical director to assume responsibility for administering all medical services performed by the narcotic treatment program.
(3) The medical director 's responsibilities include the following:
(ii) Supervision of licensed practical nurses if the narcotic treatment program does not employ a registered nurse to supervise the nursing staff. In addition, the medical director in these instances shall ensure that licensed practical nurses adhere to written protocols for dispensing and administration of medication.
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Observations
Based on a review of personnel documentation, the narcotic treatment program failed to verify that the Northwest Health System registered nurse [corporate employee] was at Parkside to supervise the licensed practicing nurses.
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Plan of Correction
Supervision of the licensed practical nurses will be done by the Medical Director and the registered nurse will assist the Medical Director as needed.
The Medical Director will have scheduled bi-weekly supervisory meetings with the nurse supervisor, nurse managers and LPN dispensing nurses to discuss policy and procedures
regarding medication, take homes, and other medical protocol for medication assisted treatment.
The Medical Director is responsible for implementing this plan of action and will ensure this deficiency does not recur.
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on a review of physician time sheets and census documents, the narcotic treatment program (NTP) failed to document physician services at least 1 hour per week for every ten patients.
The NTP had an average census of 900 patients from December 24, 2007 through March 31, 2008 which required 90 hours of physician services per week.
Time sheets for physicians indicated that from December 24, 2007 through March 31, 2008 the physicians' services provided ranged from 16 hours per week to 87.75 hours per week.
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Plan of Correction
The NTP will ensure there are enough physician services provided per regulations. Two full time doctors were hired and one part time doctor.When physicians are out for an extended amount of time or resign the Medical Director will be responsible for making sure there is 1 physcian hour for every 10 clients by utilizing staff care. The Medical Director will be responsible for ensuring the corrective action is implemented and ensure this deficiency does not happen again. |
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 a review of patient records, the narcotic treatment program failed to, with patient's consent, contact the previous narcotic treatment program for the patients' treatment history in two of two records reviewed, #18 and 36.
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Plan of Correction
The intake specialist will obtain consent from each client who has been previously treated at another NTP and obtain the records. There will be 100%audit of all intake records which will look for consents signed by new clients who have previously been treated by another program. The intake supervisor will enusre the defiency does not recur and is responsible for ensuring the corrective action is implemented. |
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
Based on a review of patient records, the narcotic treatment program failed to document that pregnant patients received prenatal care either by the narcotic treatment program or by referral to appropriate health-care providers in two of five records reviewed, #9 and 34.
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Plan of Correction
Parkside will provide documentation in the medical record of all referrals to appropriate health care facilities for all pregnant women.The physician meets with all pregnant women on a scheduled basis to encourage and monitor pre-natal care and or referrals. Staffings with the physician, supervisor and counselor of record will be documented. Both the counselor and physician will document all information in the medical record all appointments and or referrals.
The Medical Director and counselor of record and supervisor will be responsible for implementing this action and on-going compliance |
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
Based on a review of patient records, the narcotic treatment program failed to document in the counseling records and other appropriate records the nature of prenatal support provided by the narcotic treatment program in two of five records reviewed, #9 and 34.
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Plan of Correction
All pregnant clients will be assigned to one counselor. The counselor will document in the counseling records all information regarding pre-natal support for each pregnant client.The supervisor will monitor for compliance and will ensure this defiency does not recur. |
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 observations, the narcotic treatment program failed to maintain confidentiality of patients. Individual counseling sessions between counseling staff and patients and clinical consultations regarding patients were conducted with open office doors, thus the sessions were audible to anyone in the vicinity.
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Plan of Correction
Staff was instructed by memo and in supervision to close all doors during counseling sessions. Periodically supervisors will walk around and check. This will be done immediately. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the narcotic treatment program failed to obtain a monthly urinalysis in 3 of 38 records reviewed, #13, 16 and 28. Monthly drug-screening urinalysis were missing for November 2007 in record #13, missing for November 2007 through March 2008 in record #16, and record #28 was missing the urine drug screen for January 2008.
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Plan of Correction
A urine drug test or oral swab test will be obtained from all clients who are treated during any month per regulations. Nurses will check weekly and alert counselors as to which clients have not had there monthly drug test. The nurse manager will be responsible for ensuring this corrective action is implemented and that this deficiency does not recur. |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on a review of patient records, the facility failed to document that the physician reviewed the methadone dosage levels twice a year in 5 of 10 records reviewed, patients #4, 15, 20, 30 and 32.
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Plan of Correction
The Medical Director will ensure dosage levels are reviewed twice a year. The nurse has been instructed to stamp each chart the date of the medication visit. This is put immediately on the doctor's schedule for review.The Medical Director and nurse manager will monitor this plan of correction for on-going compliance and ensure this deficiency does not recur. |
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 document the narcotic treatment physician's determination of take home privileges in 4 of 5 records reviewed, #13, 15, 26 and 32. The physician's determination based on consultations with staff involved in the patient's care was not documented.
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Plan of Correction
The take home form will document the consultation between staff and the physician. The take home bottle form will be revised to include a section for the physician to write his or her comments based on the consultation and support documents with the counselor or supervisor. By doing this should keep this deficiency from recurring. The Program Director and AssistantProgram director will ensure the corrective action is implemented. |
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 narcotic treatment physician failed to document the rationale for permitting take-home medication in 4 of 5 records reviewed, #13, 15, 26 and 32.
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Plan of Correction
A section will be added on the take home form for the treatment physician to document his or her rationale for giving the client take home medication.
The Program Director and Assistant Program Director will be responsible for ensuring the corrective action is implemented. The physician will ensure the form is filled out correctly and that this deficiency does not recur. |
715.16(c)(3)(i-viii) 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:
(3) A narcotic treatment program may permit a patient to reduce attendance at the narcotic treatment program for observation to one time weekly and receive no more than a 6-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 years.
(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.
(v) A patient demonstrates no major behavioral problems.
(vi) A patient is employed, is actively seeking employment, attends school, is a homemaker or is considered unemployable for mental or physical reasons.
(vii) A patient is not known to have abused alcohol or other drugs within the previous year.
(viii) A patient is not known to have engaged in any criminal activity within the previous year.
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Observations
Based on a review of the policies and procedures manual and patient records, the narcotic treatment program failed to document call backs [unscheduled return to the facility upon short notice to verify number of take-home doses and conduct a urine drug screen] were conducted per the programs policy in 4 of 5 records reviewed, #26, 28, 30 and 32.
One patient continued to receive a 6-day take-home supply of medication even though documentation indicated that the patient continued to test positive for illicit drugs during random drug screenings and without physician justification, #15.
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Plan of Correction
The Medical Director and Nurse manager
will ensure that all call backs are documented according to regulation.
The facility will correct the defiency and will take action to ensure this defiency does not recur by the following:
Each call back will be documented in a designated binder that is lableled call backs. For each call back a UDS will be taken and and the date of the UDS will be put beside the name of the client who came in for the call back.
The nurse manager will conduct monthly checks to ensure compliance with policy.
When a positive drug screen is received the nursing department immediatley removes all takehomes pending investigation and case consult with the physician, counselor, patient and supervisor.
The patient with the positive test for illicit drugs will no longer have take homes. |
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 a review of the policies and procedures manual and patient records, the narcotic treatment program failed to document the rationale for a patient receiving a 13-day take-home supply of medication in one of one record reviewed, #30 nor did Parkside Recovery request an exception from the Division for the 13 day take-home supply. The clinical justification only indicated that this patient had been in treatment since 1984. In addition, the drug screening urinalysis results for March 10, 2008 indicated in this patient tested positive for illicit use of benzodiazepines.
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Plan of Correction
"The physician will be responsible for receiving all exception forms with the take home request and to make sure all attached information show the exceeption has been faxed to the Department of Health. The physician will not sign any take home request that does not have the right information. The faxed cover sheet and confirmation sheet will let the physician know the form has been faxedTakehome forms have been re-designed to include a section that addresses the complete rationale for receiving take homes. No take homes will be approved without a complete rational for receiving takehomes and a multidisciplined case consult. The physician will review all requests that require exceptions and ensure that they are completed in all cases before takehomes are permitted. The positive urine drug screen in client #30's chart noted was for another client with a similar name and occurred due to a filing error by medical records. Medical records clerks will receive additional training within the next 14 days from the medical records supervisor on the importance of accurate filing. |
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 a review of patient records and medication orders, the narcotic treatment program physicians' failed to communicate the subsequent dose and schedule to the person responsible for the administration of medication in 1 of 38 records, patient #5. In addition, the medication order, electronically written and signed by the physician, was rejected after 24 hours by the computer program and the automated dispensing system reverted back to the last known dosing order for the patient. Hence, negating the correct, current order.
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Plan of Correction
Net smart has informed us that they can not change our present software system due to it being out dated as a dos program.
The software will inform the nurses there is an unacknowledged physician order and the nurses have been re-trained by the Medical Director not to proceed when this message occurs. The nurse will cease any dosing activity for the that client until that client has been seen again by the physician and a new order has been written and accepted. There are staff consequences for any staff who fail to follow this new policy. The Nurse Manager and Medical Director are responsible for auditing files and ensuring this does not recur.
NHS is in the process of changing all of the NHS operations over to a new software system called Avitar within the fiscal year of July 1 2008 -June 30, 2009. Meetings have already occured to begin the dialogue of how this process will take place. |
715.17(c)(4)(i-viii) 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:
(4) Method for control and accountability of drugs. A narcotic treatment program shall develop and implement written policies and procedures regarding who is authorized to remove drugs from the storage area and the method for accounting for all stored drugs. An agent or other drug prescribed or administered shall be documented on an individual medication record or sheet in a manner sufficient to maintain an accurate accounting of medication at all times and shall include:
(i) The name of the medication.
(ii) The date prescribed.
(iii) The dosage.
(iv) The frequency.
(v) The route of administration.
(vi) The date and time administered.
(vii) The name of the person administering the medication.
(viii) The take-home schedule, if applicable.
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Observations
Based on a review of the policies and procedures manual and patient medication records April 14 through 17, 2008, the narcotic treatment program failed to maintain an accurate account of who was authorized to prescribe medications in 38 of 38 records reviewed, #1-38. The medication administration records named the previous Medical Director, who resigned at the end of December 2007, as one of the prescribing physicians.
The physician's medication orders were missing in 11 of 38 patient records reviewed, #2, 4, 5, 7, 8, 9, 16, 18, 20, 22 and 32.
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Plan of Correction
Parkside informed the IT department of NHS of this problem and they will take the name of the Medical Director who is no longer with us off the system and put the new Medical
Director's name on all programmed forms. It has alreday been done in the AMS system that generates the monthly daily dose record. This was corrected immediately. The nurse manager was instructed by the Medical Director and Program Director to have all physician's orders filed in the the chart immediatley after the physician has signed the computer generated order. Monthly Chart audits samples will help the Medical Director see if the corrective action plan is being followed. The Medical Director is responsible for ensuring the corrective action is implemented. The Medical Director and Program Director will ensure this does not recur. |
715.20 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.
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Observations
Based on a review of the facility's policies and procedures, the narcotic treatment program failed to develop a policy that stated a patient would be transferred to another narcotic treatment program within 7 days of the request of the patient. The policy and procedure regarding patient transfers stated that a patient would be transferred if the narcotic treatment program determined the transfer to be in the best interest of the patient.
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Plan of Correction
The wording in the policy will be changed by the ASU Director to remove the sentence that has in the best interest of the patient. This will be done within the next 14 days The changed policy will be given to the Project Director to present to the governing body for approval. The next governing meeting will not occur until September 2008. The ASU Director is responsible for ensuring the corrective action plan is implemented. |
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 a review of patient records, the narcotic treatment program failed to document that patient records were transferred, with patient consent, to the receiving narcotic treatment program in three of five records reviewed, #2, 4 and 38.
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Plan of Correction
The Program Director and Assistant Program Director will train all supervisors and counselors on the policy, procedures and forms used to transfer a client. Supervisors and counselors will document in the patient record that the records were faxed and get confirmation of the faxed information as well as the a name fo the person they talk to to confirm the transfer. This will be done by attaching the cover sheet with the list of what was faxed and the confirmation sheet showing that the information was received. The client will have signed a consent form that requested a transfer. By auditing the chart,the supervisor will check for all documents for transfer to be in the chart. The supervisor is responsible for ensuring this corrective action plan is implemented and will also ensure this deficiency does not recur. |
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 a review of the policies and procedures manual and 38 patient records, the narcotic treatment program (NTP) failed to develop an involuntary termination policy and procedure that was consistent with the regulations. The NTP policy and procedure exceeded the conditions stated under (1)(i)-(iv). The conditions included having a weapon on the premises and falsifying urine drug screen samples. Patients were required to sign the program's rules form that included the above conditions as grounds for immediate termination from the program.
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Plan of Correction
The program rules form have been amended to state that violation of program rules may result in program sanctions including but not limited to designated time dosing, revocation of all privileges and behavioral contract. The program Director will be responsible for seeing that the form clients sign with the program rules is changed immediately. |
715..23(b)(1) LICENSURE Patient records
(b) Each patient file shall include the following information:
(1) A complete personal history.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document a complete personal history in 5 of 8 records reviewed, #4, 5, 7, 22 and 34.
Personal histories contained incomplete and unanswered questions regarding the patient's family, employment/vocation and sexual histories in two records #5 and 7.
Personal histories were completed later than 30 days from the date of the patient's admission as required by the program's policies and procedures in three records #4, 7 and 34.
The personal history was missing in one record, #22.
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Plan of Correction
The Program Director and Assistant Program Director will train the staff on how to complete personal histories forms and the time frame in which the form is due in a formal training. The supervisors will also continue to help those counselors who continue to need training in supervision sessions. The supervisor who audits files for completion will ensure the deficiency does not recur and that the corrective action plan is implemented. The Director and training department manager will make sure the training occurs. |
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 a review of patient records, the narcotic treatment program failed to document case consultation notes regarding the patient at least once every ninety days or yearly after the patient has been in treatment for one year in 6 of 13 records reviewed, #2, 4, 8, 20, 34 and 38. Case consultations were completed later than ninety days in four records, #2, 4, 8 and 20. Case consultations were missing in two records, #34 and 38.
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Plan of Correction
The Supervisors will train all counselors on clinical documentation, the time frame that case consults and other documents are due and ensure they are done on time by utilizing their documentation work sheets and reviewing them with each counselor during weekly supervision . Also during supervision the clinical supervisor will continue this training for those counselors who continue to need help. The Assistant Program Director will follow up with this in her supervision of clinical supervisors and review of documentation work sheets. |
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 a review of patient records, the facility failed to document a complete psychosocial evaluation in 9 of 9 records reviewed, #4, 5, 7, 10, 14, 16, 34 and 36. Psychosocial evaluations were historical with patient stated comments rather than a clinical assessment of the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that may inhibit treatment, patient's attitude toward treatment and overall impressions/conclusions by the clinician.
Psychosocial evaluations were completed later than 30 days as required by the program's policies and procedures in three records, patients #4, 7 and 34.
The psychosocial evaluation was missing in one record reviewed, patient #22.
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Plan of Correction
The Program Director and the Assistant Program Director will be do a formal training for all counselors and supervisors on how to complete personal histories which will include evaluation assessments and time frames these forms are due. After the formal training the Supervisors will continue to review with and train all counselors who continue to have problems with completing clinical documentation correctly and on time. The supervisor will continue to address the time frame which a psychosocial evaluation is due, how to complete this form and how to make a clinical assessment. The supervisors who will be reviewing the chart documentation will ensure the deficiency does not recur. The formal trainign is scheduled to be done on 6-9-08. Any counselors who miss this training will be trained at the next training which will occur by July 1, 2008. |
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 a review of patient records, the program failed to document follow-up information regarding the patient in 3 of 6 records reviewed, patients #2, 8 and 38.
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Plan of Correction
The Program Director and Clinical Supervisors will train and dissuss with all counselors the importance of documenting follow up from previous treatment sessions. Supervisors will be aduiting files which include reading progress notes. Notes that do not follow up on actions from previous notes will be discussed with the counselor and the counselor will be instructed to discuss it at their next indiviudal session. This will be followed up in supervison sessions with counselors. The Clinical Supervisor will be ressponisble for implementing the corrective action and ensuring this deficiency does not recur. this is scheduled to occur in a fomral trianing session 6-9-08. Any counselors who miss this training will recieve the training by July 1, 2008. |
715.23(d) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
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Observations
Based on a review of patient records, the program failed to document a complete individual treatment and rehabilitation plan in 6 of 7 records reviewed, #5, 7, 18, 22, 24 and 34.
The individual treatment and rehabilitation plan was missing in one record, #34.
The individual treatment and rehabilitation plans were completed prior to the completion of the psychosocial evaluation in two records, #7 and 22. The program's policies and procedures stated that the individual treatment and rehabilitation plan will be completed after the psychosocial evaluation.
The individual treatment and rehabilitation plans contained short and long-term goals that were identical, as noted in record #5 where the patient is a "she" and the goals were for a "he", in three records reviewed, patient #5, 18 and 24.
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Plan of Correction
The Program Director and Assistant Director will address this deficiency in the formal training for all counselors. the training will include the order in which each document(Pyschosocial,evaluation,and treatment plan) is to be completed. The psychosocial is done first and then the psychosocial evaluation and third the treatment plan. Training will be done on how to complete a treatment plan correctly including how to write short and long term goals.
The Program Directorand Assistant Program Director will be responsible for implementing the corrective action plan and the Clinical Supervsiors will be responsible for ensuring the deficiency does not recur. |
715.23(d)(1) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(1) The treatment plan shall identify the behavioral tasks a patient shall perform to complete each short-term goal.
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Observations
Based on a review of patient records, the program failed to document a complete individual treatment and rehabilitation plan that identifies the behavioral tasks to be performed by the patient in 6 of 7 records, #5, 7, 18, 22, 24 and 34.
The individual treatment and rehabilitation plan was missing in record #34.
The treatment plan was missing behavioral tasks the patient shall perform to complete each short-term goal in five patient records, #5, 7, 18, 22 and 24. Treatment plans stated what tasks the counselor will complete versus what tasks the patient will complete.
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Plan of Correction
The Program Director and Assistant Program Director will address this issue in the training on how to complete a psychosocial history, evaluation and developing a treatment plan from the information obtained. In this training we address the behavioral task the client will focus on. We will going through the process step by step so that counselors can review each page of the forms and have a clear understanding of what is needed to compete these forms. Supervsiors will review treatment plans and enure the corrective action is implemented and ensure this deficiency does not recur. Supervisors will also ensure the indiviudal rehabilitation plan is completed. The training will occur by 6-16-08 and any counselor who miss this training will be trained by July 1, 2008. |
715.23(d)(2) 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.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Based on a review of patient records, the narcotic treatment program failed to document treatment and rehabilitation plan updates at least every 60 days in 10 of 11 records, patients #1, 3, 7, 11, 15, 16, 20, 26, 28 and 34.
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Plan of Correction
The Program Director and the Assistant Program Director will train counselors on how to complete a treatment plan correctly. In this training we will address the behavioral task the client will focus on and completion of the rehabilitation plan. Supervisors will follow up in supervsion with counselors who need extra assistance. Supervisors will aduit records and review treatment plans on an on-going basis and ensure the corrective action plan is being followed and that the this deficiency does not recur.
Supervisors will ensure that the individual rehabilitative plan is completed and filed. The training will take place by 6-16-08 and any counselor who miss this training will receive training by July 1, 2008.
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715.28(b)(1-4) LICENSURE Unusual incidents
(b) These policies and procedures shall include the following:
(1) Documentation of the unusual incident.
(2) Prompt review and investigation.
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
(4) Ongoing monitoring of the corrective action plan.
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Observations
Based on a review of monthly incident reports for July 2007 through March 2008, the narcotic treatment program reviewed the incident, but failed to develop a corrective action plan and monitor its implementation.
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Plan of Correction
A review of the old process was reviewed by the Program Director and Incident supervisor. A new process has beem implemented and all staff has been made aware of this process.This new proscess will ensure all relevant pages of the incident report are completed and the supervisor will document and monitor all corrective action taken.
The following steps will take place:
The first page of the incident is documented by the staff member who is directly involved or sees the incident. This report will be given to the incident supervisor who goes to scene of incidents or designates someone to go in his absence. He will then read the report and give to the appropriate supervisor and or counselor. He will attend to the incident and involve the counselor and or supervisor as needed. The incident supervisor will fill out the remaining pages of the the incident report to incldue all actions/corrections that take place in reference to the incident.
The Incident supervisor will discuss all incidents in his monthly meeting with his committee and they will discuss also the resolution. These reports will be given to the Program Director for review so she can see the corrective action is documented on the form. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on a review of monthly incident reports for July 2007 through March 2008, the narcotic treatment program failed to report with the Department within 48 hours of the death or serious injury due to trauma, suicide, medication error or unusual circumstances and incidents with potential for negative community reaction or concern.
An incident report dated February 28, 2008 indicated the therapist was notified by another patient that patient #5 was seen being carried out of the house in a body bag on February 25, 2008. In addition, the report indicated the therapist contacted patient #5's emergency contact person, without the executor of the patient's estate consent, to confirm the death. No incident report was filed the the Department.
An incident report dated February 1, 2008 indicated that a "code blue" was called for a patient while the patient was at the facility. Fire rescue transported the patient to a locale hospital. No incident report was filed with the department.
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Plan of Correction
The new supervisor in charge of incident reporting will report all unusual incidents to the Department of Health per regulation 715.28 ©1-5. The Incident Supervisor will review all unusual incidents in our Monday supervisor's meeting. He will show confirmation of them being sent to the Department of Health( Faxed Confirmations will be attached to the report) The Program Director is responsible for ensuring the corrective action plan is implemented. The Incident Supervisor will ensure this dificiency does not recur.
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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
Based on a review of patient records, the narcotic treatment program failed to request an exception from the Department and maintain documentation of the exception in the patient's record in one of one record reviewed, patient #30. Patient # 30 was given 13 take-home doses which is not permitted by regulation.
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Plan of Correction
The Medical Director has reviewed the regulations regarding take home exceptions with program physicians. The Program Diirector did the same with the supervisors and counsleors. After their case consult and review of rationale for take homes, the physician will ensure there is an exception form for all take home request that require an exception form. The form will be provided to them by the counselor and it will show confirmation it has been faxed to the Department of Health. The physician will not sign off on ay take home request if they do not see the fax confirmation sheet and the exception form for take home request that required an exception. The Medical Director will implement the corrective action and ensure the deficiency does not recur.
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