INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and monitoring for the use of a narcotic agent in the treatment of patients conducted on December 15 & 16, 2016 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Narcotic Addict Rehabilitation Program of Thomas Jefferson University was found not to be in compliance with the applicable chapters of 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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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection conducted on December 16, 2017, the facility failed to enure that the wall of the waiting area and the physician's office were in good repair.
There was a hole in the wall in the waiting are across from the dosing window and a hole in the wall adjacent to the desk in the physician's office.
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Plan of Correction
The wall in the waiting room has been repaired as of 2/20/17. The wall in the physician's office will be repaired by 4/15/17. Routine review of the facility, including the walls in the waiting area and the offices, to be conducted by maintenance personnel with a report issued to the Facility Director, will ensure future compliance. |
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 upon the documented patient census at the time of the inspection, the facilty failed to ensure that narcotic treatment physician services were provided onsite at least 1 hour per week for every ten patients
The facility documented that they had 414 patients as of the date of the inspection, but only documented 40 hours per week for physicians hours. The Medical Director was documented as having worked 32 hours and the physician was documented as having worked 8 hours.
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Plan of Correction
It is the responsibility of the Division Director to ensure adequate weekly medical coverage. Current plans include expanding the hours of the medical director and/or hiring of additional personnel (in all likelihood a CRNP) to allow us to be compliant with the standard. |
715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of patient records, the facility lacked documentation in the patient record verifying the identification, age and/or emergency contact information relative to the patient in three of seven records reviewed.
Seven patient records were reviewed on December 15 & 16, 2016 for documentation verifying patient identification, age and/or emergency contact information. Three of seven records reviewed lacked one or more of the required documentation.
Patient records #2 and 4 lacked documentation for an emergency contact.
Patient record #3 lacked documentation verifying the identification and age of the patient.
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Plan of Correction
It is the responsibility of the Program Coordinator to ensure that each individual is properly screened for eligibility upon admission, specifically to verify the identity of each individual and their information for each individual's emergency contact. The Intake Coordinator will make a copy of each individual's current and valid state identification to verify name, address, and date of birth, and will place a copy of the identification in the individual's chart. The Intake Coordinator will also have each individual sign a release of information for their emergency contact. The release will include first and last name and phone number of the emergency contact and will be signed by the individual and witnessed by the Intake Coordinator. The Program Coordinator will check each individual's chart to ensure compliance upon admission. The Coordinator of Treatment and Training will conduct random chart audits monthly to ensure compliance on an ongoing basis. Patients #2 and #4 will have emergency contact releases completed no later than 3/31/17. Patient #3 will have a copy of her ID placed in her patient record no later than 3/24/17. |
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 conduct semi-annual reviews of dosage levels in two of three records where required.
Seven patient records were reviewed on December 15 & 16, 2016, three of which required documentation that the dosage levels were reviewed at least twice a year occurring at least two months apart.
Patient record #2 contained documentation of a review conducted on May 13, 2016 with the one prior to that occurring on 12/23/2014.
Patient record #4 contained documentation of a review conducted on September 22, 2015 with no subsequent reviews as of the date of the inspection.
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Plan of Correction
Medical personnel have been reminded of the need for bi-annual dosage level reviews for all individuals enrolled in methadone maintenance treatment. Dose reviews will be completed during Annual Physical Evaluations and six months thereafter and will be tracked via spreadsheet by the Medical Director Compliance will be ensured via random audit of clinical records to be conducted by administrative personnel, including the Facility Director, Program Coordinator, Clinical Supervisors, and Coordinator of Treatment and Training. Patients #2 and #4 will receive dose reviews by 3/31/17. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to ensure that patients were provided with thre required number of counseling hours in one of four records reviewed.
Seven patient records were reviewed on December 15 & 16, 2016, four of which were reviewed for the provision of counseling hours.
Patient #2 was admitted to the program on December 17, 2013 and was required to have a minimum of one hour of group or individual psychotherapy every two months. Patient #2's last documented session was for .50 hours on 10/3/16.
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Plan of Correction
Clinical staff will be trained via an in-service session conducted by the Facility Director on the need to provide minimally 2.5 hours of care in the first two years of treatment. A key component of this in-service will be utilization of motivational interviewing strategies as a means for promoting engagement and attendance. This in-service will occur by 4/15/17. Random review of all clinical records, including real-time feedback to clinical staff, to be overseen by the Coordinator of Treatment and Training, will ensure compliance with the standard. Patient #2 will be seen for 2.5 hours of individual psychotherapy monthly by 4/30/17 and ongoing thereafter. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of patient records, the facility failed to conduct annual physical exams in two of two records where required.
Two records requiring documentation of annual physical exams were reviewed on December 15, 2016.
Patient record #2 contained documentation of a physical exam conducted on May 13, 2016 with the one prior to that occurring on 12/23/2014.
Patient record #4 contained documentation of a physical exam conducted on September 22, 2015 with no subsequent reviews as of the date of the inspection.
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Plan of Correction
Medical personnel have been reminded of the need for annual physical evaluations for all individuals enrolled in methadone maintenance treatment. Annual Physical Evaluations will be completed on each patient every 12 months and will be tracked via spreadsheet, to be managed by the Head Nurse. The Coordinator of Treatment and Training will be responsible for conducting random monthly audits to ensure compliance with Annual Physical Examinations. Patients #2 and #4 will receive Annual Physical Evaluations by 3/31/17. |