INITIAL COMMENTS
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This report is a result of an on-site on-site follow-up inspection regarding the plans of correction for the inspection conducted for the approval to use narcotic agents, specifically methadone and buprenorphine, in the treatment of narcotic addiction conducted on April 14, 15, 16 and 17, 2008 by staff from the Division of Drug and Alcohol Program Licensure. The follow-up inspection was conducted on November 13, 2008 an November 19, 2008 in conjunction with the follow-up to the July 22, 2008 complaint and the November 19, 2008 Licensure Inspection 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 January 26, 2009.
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Plan of Correction
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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
Original Citation from 04/17/2008 Inspection:
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.
FINDINGS OF FOLLOW-UP INSPECTION:
Based upon a review of eighteen client records on 11/13/2008, two records required that the request and exception for the 13 day take-home supply. The facility failed to request an exception from the Division for the 13 day take-home supply in one of two client records where required, specifically #7.
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Plan of Correction
The facility will send an exception request for the file which was missing an exception request. This will be done by 2-6-09. The clinical supervisor of medical records will be responsible for faxing the exception request to the Division of Drug and Alcohol Program. The Clinical Supervisors will be responsible for sending the exception request to the Division of Drug and Alcohol Programs after approval from the Medical Director to ensure this deficiency does
not recur.
Additionally, The Assistant Program Director will train the clinical supervisors and the clinical supervisors will conduct training sessions with all staff on March 2nd, 2009 regarding the requirements and procedure for submitting exception requests for any 13 day take-home supplies. The Clinical Supervisor and Medical Director will review all requests and will fax those that meet the requirements to the Division of Drug and Alcohol Program Licensure for final decision. No take-homes will be given to any client prior to receiving approval from the Division of Drug and Alcohol Program Licensure.
Completed by March 2, 2009
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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
Original Citation from 04/17/2008 Inspection:
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.
FINDINGS OF FOLLOW-UP INSPECTION:
Based upon a review of the policies and procedures manual on 11/13/08, and a faxed copy of the policy and procedures relating to the Involuntary Client Termination on 12/18/08, 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 excessive absences from the program, consistently abnormal toxicology tests, and failure to seek employment, training, and education when determined to be appropriate by staff.
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Plan of Correction
The program will change the involuntary termination form and policy to comply with 715.21 (1)(i-iv) This would include changing the involuntary termination and policy to include: "...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.
Completed by February 16, 2009
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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
Original Citation from 04/17/2008 Inspection:
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.
FINDINGS OF LICENSING INSPECTION:
Based on a review of client records, the facility failed to document psychosocial evaluations in five of fifteen client records.
Twenty-five client records were reviewed on November 17-19, 2008. Psychosocial evaluations were required in fifteen client records. The facility did not document psychosocial evaluations in client records # 2, 6, 8, 9 and 13.
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Plan of Correction
The clinical supervisor will monitor and review each week in supervision with the counselors the time frame in which a psychosocial evaluation must be completed. Clinical Supervisors will be re-trained by the Assistant Program Director on what to look for in the psychosocial evaluation of a client including the use of clinical assessments as opposed to client statements. The Assistant Program Director will review a sampling each month of psychosocial evaluations recently completed to ensure compliance regarding timeliness and quality of evaluations.
Completed by: January 26, 2009 |
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
Original Citation from 04/17/2008 Inspection:
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.
FINDINGS OF LICENSING INSPECTION:
Based on a review of client records, the facility failed to document follow-up information in four of eight client records.
Twenty-five client records were reviewed on November 17-19, 2008. Follow-up information was required in eight client records. The facility did not document follow-up information in client records # 21, 22, 23 and 25.
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Plan of Correction
Counselors will document in the clients charts all follow ups completed after clients are discharged. Clinical supervisors will monitor the follow ups in weekly supervision to ensure this deficiency does not recur.
Completed: Immediately |
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
Original Citation from 04/17/2008 Inspection:
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.
FINDINGS OF FOLLOW-UP INSPECTION:
FINDINGS OF FOLLOW-UP INSPECTION:
Based upon a review of eighteen client records on 11/13/2008, two records required that the request and exception for the 13 day take-home supply. The facility failed to request an exception from the Division for the 13 day take-home supply in one of two client records where required, specifically #7.
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Plan of Correction
The facility will send an exception request for the file which was missing an exception request. This was done by 2-6-09. The clinical supervisor of medical records will be responsible for faxing the exception request to the Division of Drug and Alcohol Program. No takes home will be given until the facility receives the faxed confirmation form from the Division of Drug and Alcohol Program granting the exception. Clinical supervisors will ensure this practice occurs.
Additionally, The Assistant Program Director will train the clinical supervisors and the clinical supervisors will conduct training sessions with all staff on March 2nd, 2009 regarding the requirements and procedure for submitting exception requests for any 13 day take-home supplies. The Clinical Supervisor and Medical Director will review all requests and will fax those that meet the requirements to the Division of Drug and Alcohol Program Licensure for final decision. No take-homes will be given to any client prior to receiving approval from the Division of Drug and Alcohol Program Licensure.
Completed by March 2, 2009
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