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 May 13-16, 2013 by staff from the Division of Drug and Alcohol Program Licensure. 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 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 patient records, the facility failed to document in the patient record that a face to face determination of current and at least one year of physiological dependency in three of four patient records reviewed.
The findings include:
Twenty four patient records were reviewed May 13-16, 2013. Four patient records were reviewed for documentation by the narcotic treatment physician of making a face to face determination of current and one year physiological dependency
Patient # 1 was admitted July 16, 2012. The patient had previously attended treatment at the facility. The patient entered into a treatment center for detoxification and was there July 4 to July 9, 2013. The patient was detoxified from opiates. The facility obtained an initial urine drug screen July 11, 2013 at which time it was negative for opiates. Another drug screen was taken on July 12, 2013 at which time the screen was positive for barbiturates, benzodiazapine and marijuana. A drug screen on July 17, 2013, a day after admission and first dose, was positive for barbiturates, benzodiazapine, marijuana, methadone and opiates. This was the first urine drug screen positive for opiates. There was a notation the patient had been detoxified with buprenorphine prior to this admission. There was no documentation of current dependency or the physician's justification for admitting the patient without current dependency.
Patient # 16 was admitted February 26, 2013. There was no documentation by the narcotic treatment physician of current and at least one year of physiological dependency.
Patient # 18 was admitted February 22, 2013. There was no documentation by the narcotic treatment physician of having completed a face to face determination of current and at least one year of physiological dependency.
A discussion with facility medical staff confirmed the finding.
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Plan of Correction
It is the responsibility of the program physician to document in the clinical record at least one year of physiological dependency during the admission process. Chart audit will be conducted to ensure compliance. Admissions for whom minimally one-year of physiological dependence cannot be documented and/or test negative negative for opiates, will be evaluated for appropriateness for stabilization on methadone. If in the clinical judgment of the program physician methadone is the treatment of choice, the physician will apply for an exception from the state to initiate this patient on methadone. Once approval has been granted, the patient will be re-evaluated for an initial dose. To ensure compliance, the intake coordinator will maintain a log of patients requiring such documentation and this log will be reviewed quarterly by the Medical Director.
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715.21 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.
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Observations
Based on review of patient records, the facility failed to ensure all efforts had been initiated to retain the patient prior to threatening involuntary termination.
The findings include:
Patient # 12, was admitted November 6, 2006 and discharged as non-compliant on March 12, 2013. The counselor had received notice from the funding source that the patient was prescribed benzodiazapine. The patient's urine drug screen did not show positive for benzodiazapine. When confronted, the patient was told he must sign a consent to release information for the prescribing physician and if he refused, which he did, then he would be involuntarily detoxified. There was no documentation of any evidence the patient was diverting the prescribed medication nor was there evidence he was ingesting the prescribed medication. There was no documentation of any attempt to address the concerns therapuetically prior to the threat of discharge.
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Plan of Correction
It is the policy of Jefferson's Division of Substance Abuse taht involuntary termination of a patient should be initiated only after all efforts to retain the patient in treatment have failed. To ensure compliance, clinical staff will be trained by the Program Coordinator about the appropriate use of involuntary termination procedures. In addition, program supervisory personnel (i.e., Program Coordinator, Clinical Supervisor) will review each planned involuntary termination to review efforts made towards retention of the client. |
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 the review of administrative documentation, the facility failed to provide documentation of incident reports involving patient deaths, incidents with the potential for negative community reaction or drug related hospitalizations to the Department within 48 hours as required.
The findings include:
Administrative documentation that included the unusual incident reports was reviewed May 14, 2013.
Patient A on July 25, 2012 appeared to overdose in the office and was sent to hospital after 911 was called.
Patient B on February 13, 2013 had a possible suicide attempt by overdosing on heroin and cocaine. 911 was called and the police arrived to transport him to psychiatric facility.
Patient C on March 19, 2013 appeared sluggish with a delayed response to external stimulus and 911 was called and the patient was transported to the hospital.
Patient D on April 18, 2013 was found slumped against the outside wall of the facility and was unconscious.
Patient E on April 29, 2013 was unresponsive in group. Emergency services were called and the patient was transported to the hospital as a possible overdose.
Patient F was transported to the hospital via ambulance with complaints of not "feeling right" after she was medicated at the facility.
There was no documentation that any of these were reported to the Department as required.
Patient # 3 was last medicated on March 1, 2013. The facility learned of the death from an obituary March 5, 2013. The patient record was discharged March 8, 2013. An incident report was sent to the Department March 21, 2013, more than 48 hours after they learned of the incident.
This was discussed with facility staff who acknowledged incident reports had not been sent..
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Plan of Correction
The findings from the May 13-16 site visit have been shared with the Medical Director. It shall be the responsibility of the Medical Director or her designee to ensure that completed incident reports relating to the 5 categories of unusual events are transmitted to the Department of Drug and Alcohol Programs within 48 hours. Faxed confirmations will be affixed to the filed incident report (on site). Quarterly review of incident reports will ensure that they are being transmitted appropriately. |