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 September 11, 12, 13, and 14, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Health Masters, Inc. 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 and a plan of correction is due on October 9, 2007. .
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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
The facility failed to have the narcotic treatment physician complete a face-to-face assessment to determine initial current dependency for prospective patients. Patient #1 was readmitted and medicated without a urine drug screen (UDS) result to confirm current dependency. Patients # 13 and 14 were also dosed prior to UDS results, the results of which were not made available until 2 days (#13) and 8 days (#14) following the initial dose. Without the UDS results and face-to-face meeting between the physician and prospective patient, current dependency cannot be determined.
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Plan of Correction
Physician will be responsible for verifying that UDS results are received by the program prior to all admissions and readmissions. Physician will complete a face to face assessment with all admissions. Facility Director
will also ensure that UDS results accompany all patients for admission
and/or readmission prior to assessment with physician. This method will
be in effect immediately.
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715.9(b)(2) LICENSURE Intake
(b) Exceptions to the requirements in subsection (a) are:
(2) Upon readmitting a patient who has been out of a narcotic treatment program for 6 months or less after a voluntary termination, the narcotic treatment program shall update the information in and review the patient 's file to show current opiate narcotic dependency, but need not conduct a physical examination and applicable laboratory tests. Privileges earned during the previous treatment may be reinstated at the discretion of the narcotic treatment physician.
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Observations
The facility failed to document current dependency for patients # 1 and 11 who were readmitted within six months of a voluntary termination.
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Plan of Correction
Physician will be responsible for documenting narcotic dependency
determination following face to face assessment for all admissions and readmissions. Facility Director and CRNP will ensure that physician is
aware of the regulations concerning documentation, and will monitor ongoing practices. This will be in effect immediately.
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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
The facility failed to document that the prior narcotic treatment program was contacted and information was requested for patient #5.
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Plan of Correction
Facility Director will instruct clinical staff to accommodate all transfer patients through director's office. Director will develop transfer packet of forms applicable to transfer patients to ensure proper documentation.
This procedure and documentation will be available and utilized by Oct.
31, 2007.
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715.9(d) LICENSURE Intake
(d) A narcotic treatment program shall explain to each patient treatment options; pharmacology of methadone, LAAM and other agents, including signs and symptoms of overdose and when to seek emergency assistance; detoxification rights; grievance procedures; and clinic charges, including the fee agreement signed by the patient.
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Observations
The facility failed to document that they provided patients with information regarding "signs and symptoms of overdose". There is no documentation on the consent to treatment form or patient handbook regarding this information.
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Plan of Correction
Patient Consent to Treatment form will be amended to include statement that the "signs and symptoms of overdose" were explained to the patient. Physician will discuss "signs and symptoms of overdose" with patient
during face to face assessment. Patient Handbook will be amended to include the signs and symptoms of overdose. These changes will be in effect by Oct. 31, 2007.
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715.9(e) LICENSURE Intake
(e) A narcotic treatment program shall secure a personal history from the patient within the first week of admission. The personal history shall be made a part of the patient record.
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Observations
The facility failed to obtain and document a personal history for patients #1, 2, 3, and 15 within one week of their admission to the facility.
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Plan of Correction
Whenever possible, the Facility Director, acting in the capacity of intake counselor, will coordinate intake schedule to allow for assignment of primary counselor to patient and documentation of personal history on date of admission. Facility Director will be responsible for instructingstaff on regulation requiring documentation of personal history within one week of admission. Facility Director will coordinate intake of patient with primary counselor to ensure that a session is scheduled and kept to obtain and document personal history within 7 days should the date of admission not be possible. This process will be in effect by Oct. 31, 2007.
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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
The facility failed to maintain compliance with regulations regarding confidentiality. Specifically, patients # 5 and 10 signed consents to release drug test results to an employer and social service agency that violated 4 Pa. Code 255.5. Patient #13 signed a consent to release information that did not include purpose for release. There was no documentation that patient # 13 was offered a copy of the consent to release information..
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Plan of Correction
Facility Director will instruct staff on program policies concerning
confidentiality, as well as a review of consent to release forms and PA Code 255.5. All staff will be instructed to document that a copy of release was offered to patient for all releases. A release form packet will be developed and presented to all staff during in-service by Facility Director for retention and use. This instruction will take place by Oct. 31, 2007.
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715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
The facility failed to obtain a signed consent to treatment from patient #1 when readmitted.
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Plan of Correction
Physician will be responsible for obtaining a signed consent to treatment from during face to face assessment for all admissions and readmissions. Facility Director and CRNP will ensure that physician is aware of the regulations concerning documentation, and will monitor ongoing practice. This will be in effect immediately.
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715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
The facility failed to update patient identification photographs for patients who have been in treatment for three or more years. Staff state they were unaware of the regulation regarding updating of patient photographs.
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Plan of Correction
Facility Director will be responsible for providing front desk personnel
with an ongoing list of patients that have been in program for 34
months. An updated photograph of these patients will be obtained
in their 34th or 35th month. This will be in effect immediately.
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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
The facility failed to obtain a urine drug screen for patient #11 during the month of August, 2007.
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Plan of Correction
Nursing staff will continue to be responsible for monitoring monthly
UDS obtained for individual patients with current tracking policy that is in place. Nursing staff will also ensure that printed results from Redwood Laboratories are in patient file within 7 days of receiving. The deficiency being addressed is a result of delayed record filing and not the ability to meet the regulation of obtaining monthly samples from each patient. Nursing supervisor will be responsible for ensuring that the current method continues to obtain 100% UDS from active patients. This will be effective immediately.
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715.16(a)(1) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(1) A narcotic treatment program may give take-home medications only to a patient who the narcotic treatment physician has determined is responsible and able to handle narcotic drugs outside the narcotic treatment program.
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Observations
The facility failed to document the physician's determination that patients were responsible and able to handle take-home doses. There was no documentation of the physician's assessment of the patient's responsibility regarding take home medication in patient charts # 2, 4, 9, 10, 11,12, and 18.
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Plan of Correction
Facility Director and Board of Directors will design and implement
a new request form for take home medication that will permit the physician to document an assessment of a patient's responsibility regarding the request for take home medication. Facility Director will be responsible for providing staff with instructions for using and implementing the form. This form and process will be effective Oct. 31, 2007.
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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
The facility failed to document that consultations between staff and the physician occur in the determination of patient eligibility for take-home privileges. The facility does utilize a form that is signed by staff and physician prior to change in take-home privileges; however, this does not address specific issues regarding the patient's status and the physician does not document the rationale for take-home status.
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Plan of Correction
Case consultations between staff and physician will occur and be documented regarding determination of take home privileges for patients. This documentation will accompany updated take home request form for all changes in privilege status. CRNP will be
responsible for monitoring inclusion of consultation for all requests. This will be effective by Oct. 31, 2007.
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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
The facility physician failed to document the rationale for ordering take-home privileges. Specifically, patients # 3, 4, 9, 10, 11, and 12 have take-home privileges with no documented physician rationale for ordering the patient's take-home status.
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Plan of Correction
Facility Director and Board of Directors will design and implement a new request form that will permit the physician to document rationale for ordering approval or non-approval of take home medication. Facility Director will be responsible for providing physician with instructions for using and implementing the form. This form
will be effective Oct. 31, 2007.
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715.16(a)(4) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(4) A narcotic treatment physician may rescind take-home medication privileges.
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Observations
The facility failed to involve the physician in the rescission of take-home medication privileges for patient # 11. The patient record indicates take-home privileges were terminated without physician involvement or order. Additionally, the facility utilized a standard take home form which stated that changes in take-home privileges are determined by clinical staff.
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Plan of Correction
Facility Director and Board of Directors will design and implement a new form that will address patient loss of privileges, and will allow physician to document assessment and rationale for decision. Facility Director will be responsible for providing physician with instructions for using and implementing the form. All changes in patient privilege status will be addressed at the interdepartmental meeting. CRNP will be responsible for monitoring inclusion of documentation prior to all patient status changes. This will be
effective by Oct. 31, 2007.
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715.16(a)(5) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(5) A narcotic treatment program shall develop written policies and procedures relating to granting and rescinding take-home medication privileges.
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Observations
The facility failed to document a policy and procedure that addressed the rescinding of take-home privileges. The facility has a policy and procedure that addressed the granting of take-home privileges but has no specific policies to address rescission and reinstatement of take-home privileges.
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Plan of Correction
Program will adjust policy to reflect that "reinstatement" of privileges will be reviewed during interdepartmental meeting with physician. Program will utilize take home privilege form to allow for physician rationale and assessment documentation, as well as staff and physician consultation. CRNP will be responsible for monitoring inclusion of documentation prior to all patient status changes. This will be effective Oct. 31, 2007.
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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
The facility failed to document that the physician considered the eight point criteria in determining take-home status. Specifically, patient # 9 had bi-weekly take home privileges but chart documentation consistently addressed instability in the patient's home. Patient # 4 had tri-weekly take-home privileges but did not attend the required minimum amount of counseling (at least 2.5 hours) during the months of July (1.25 hours) and August (2.25 hours). Patient #10 had a positive drug screen in May 2007, lost her take home privileges and was currently receiving bi-weekly take homes; there was no documentation by the physician addressing the rationale for the reinstatement of take home privileges
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Plan of Correction
Facility Director and Board of Directors will design and implement a
new form that will provide for counselor comments and physician rationale regarding the eight-point criteria when determining take home status. All privilege status changes will be addressed during interdepartmental meeting. Facility Director will instruct physician on the utilization and implementation of form. CRNP will be responsible for monitoring inclusion of documentation prior to all status changes. This will be effective by Oct. 31, 2007.
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715.17(b) LICENSURE Medication control
(b) A narcotic treatment program shall develop policies and procedures regarding verbal medication orders, including the issuing and receiving of orders, identifying circumstances when orders are appropriate and documenting orders, in accordance with applicable Federal and State statutes and regulations.
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Observations
The facility failed to follow its policy requiring that verbal orders will be signed by the physician within twenty four hours; the physician provided a verbal order for patient # 12 and did not sign it until 4 days following date of the verbal order. Physician gave a verbal order for patient # 14 and later signed and dated the order for the same date as the verbal order; physician was not at the facility on this date.
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Plan of Correction
Program will change policy to reflect that all verbal orders issued by physician will be signed by the physician within 24 hours in
accordance with applicable regulations. Facility Director will provide instruction to physician concerning regulation. CRNP will be
responsible for monitoring compliance and completion of documentation. This will be effective by Oct. 31, 2007.
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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
The facility failed to maintain a method to ensure accurate dosing of patients that included the most current medication order. On September 10, 2007, the computer system was non-operational requiring the nurses to manually medicate the patients. By staff report, the closing dosing record for all patients had not been printed on September 8, 2007. Nursing staff did not have a current, accurate means to determine if each patient's dose was correct for September 10, 2007.
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Plan of Correction
CRNP and Nursing supervisor will design and implement a "checklist" that will include end of day tasks to be completed. The closing dosing record will be included in these tasks, and
will be printed daily. CRNP will be responsible for monitoring compliance with completion of checklist weekly. Nursing supervisor will monitor checklist daily, or appoint staff member when appropriate. This will be effective immediately.
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715.17(c)(5) 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:
(5) Security of all substances. A narcotic treatment program shall develop and implement written policies and procedures to minimize the likelihood of loss, theft or misuse of an agent or another controlled substance as well as a plan of action if a loss, theft or misuse does occur. In the event of loss, theft or misuse, the Federal and State statutes and regulations regarding reporting shall be followed.
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Observations
The facility failed to have a policy that accurately reflected actions to be taken in the event of theft, loss, or misuse of a controlled substance. Policy stated that the police would be contacted should any loss, misuse, or theft occur on site; interviews with staff indicated this is not what would happen as the police would not always be called in the event of loss, theft or misuse. Facility practice needs to be consistent with facility policy and procedure and visa versa.
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Plan of Correction
The Board of Directors will be responsible for amending
policy regarding security of all substances to read: " In the event of
spillage, loss, theft or other misuse of medication, it will be Health
Masters policy to initiate an incident report with the Facility Director
and the Program Compliance Officer. Spillage, loss, or other misuse of
medication will be documented through the use of an incident report
within 24 hours of occurrence. Notification will be promptly made to
the Department and DEA by Facility Director. In the event of theft, an
incident report will be completed and Facility Director and Compliance
Officer will be notified immediately, as well as the Department, DEA,
and local law enforcement." This will be effective Oct. 31, 2007.
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715.18(a)(1) LICENSURE Rehabilitative services
(a) A narcotic treatment program shall provide, either onsite or through referral agreements, a full range of rehabilitative services. Rehabilitative services shall include:
(1) HIV education services.
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Observations
The facility failed to document the availability of HIV education services for the patients.
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Plan of Correction
Patient Handbook, which currently states that HIV education services
are available from Health Masters, will be amended to state that HIV
education services are available to Health Masters patients from Progressive Home Health in Monaca, PA. Facility Director will be responsible for amendment to handbook. HIV education material will continue to be given to all patients at an orientation meeting. Material will also be available to patients in reception area. These changes and actions will be effective by Oct. 31, 2007.
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715.18(a)(3) LICENSURE Rehabilitative services
(a) A narcotic treatment program shall provide, either onsite or through referral agreements, a full range of rehabilitative services. Rehabilitative services shall include:
(3) Adult educational services.
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Observations
The facility failed to document the availability of adult education services for the patients.
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Plan of Correction
Facility Director has obtained an updated service agreement from PA CareerLink that includes documentation of available referrals for adult training and educational services. Agreement has been signed by PA CareerLink Administrator and is effective as of Oct. 5, 2007.
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715.18(b) LICENSURE Rehabilitative services
(b) A patient shall also have the opportunity to access legal services.
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Observations
The facility failed to identify the legal services that patients may access.
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Plan of Correction
Facility Director and Board of Directors list Attorney Joseph Liberati as legal counsel that patients may access, as stated in patient patient handbook. Facility Director will be responsible for obtaining a service agreement between Health Masters and Attorney Liberati. This will be effective by Oct. 31, 2007.
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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
The facility failed to provide patients #4, 12, and 13 with the required 2.5 hours of psychotherapy each month.
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Plan of Correction
Facility Director will be responsible for monitoring counseling hours
for each counselor on a weekly basis. Counselors will be responsible
for submitting weekly summary sheets for caseload that reflects the
hours attended for patients by each week and cumulative for the
month. Facility Director and counselor will review summary on a weekly basis, which will direct intervention for patient attendance in group or rescheduled individual session. This will be effective as of Oct. 31, 2007.
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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
The facility failed to provide patients #15, 16, and 17 with written notification of their involuntary termination from the facility; per facility policy, any patient must be notified in writing and given reasons for discharge prior to any involuntary termination of services.
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Plan of Correction
Director and Board of Directors will continue to comply with 28 Pa. Code 709.33. Facility Director will conduct in services of providing written notification to patient of their involuntary termination from facility. Documentation including a newly revised form will be utilized to address action and policy. Counselor will advise patient of termination and the reasons thereof. Program will continue to provide a minimum of 7 days of detoxification services to patient. This will be effective by Oct. 31, 2007.
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715.22(b) LICENSURE Patient grievance procedures
(b) The procedure shall permit aggrieved patients a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director. If the grievance is filed against the narcotic treatment program director, the review of the case shall be conducted by either a multi-representative group of the narcotic treatment program or a subcommittee of the governing body instituted for the express purposes of grievance adjudication.
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Observations
The facility failed to afford a full and fair opportunity for patient #16 to be heard. This patient requested to speak with the facility director before being involuntarily discharged from the facility. There is no documentation that addressed whether this did or did not occur and the outcome.
The facility director stated to Division staff that there have been no grievances filed by any patient.
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Plan of Correction
Facility Director and Board of Directors will be responsible for implementing a grievance/appeal form into its extensive grievance policy. The Plan of Correction in service will address the issue that when a patient requests an appeal or files a grievance it will be in written form signed by the patient and Counselor and presented to the Facility Director who in turn will follow the existing policy. Facility Director will be responsible for providing form to all Counselors, and instructing them in the program policy. Facility Director will be responsible for ensuring that grievance procedure as per policy is followed. This will be effective by Oct. 31, 2007.
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715.23(a) LICENSURE Patient records
(a) A narcotic treatment program shall maintain patient records in conformance with 42 CFR 2.16 and 2.22 (relating to security for written records; and notice to patients of Federal confidentiality requirements) and State statutes and regulations. A narcotic treatment program shall maintain a complete file on the premises for each present and former patient of the narcotic treatment program for at least 4 years after the patient has completed treatment or treatment has been terminated. Files shall be updated regularly so that the information is current.
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Observations
The facility failed to properly maintain and record nursing notes as part of patient chart. Interviews and observation revealed that nurses have been writing progress notes in the computer dosing record and forwarding the notes to the patient's primary counselor. While on site, it was determined there was no protocol nor expected use by the nurses for this system of communication. Progress notes submitted by nurses in this manner have not been reviewed nor included in patient record.
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Plan of Correction
Nursing notes will now be printed on paper after each entry, and will be
forwarded to appropriate counselor before the nursing shift has ended.
These notes will become part of the permanent chart record for each
patient. Nursing Supervisor will be responsible for instructing nursing
staff on the proper and timely use of recording nursing notes. This will effective immediately.
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715.23(b)(2) LICENSURE Patient records
(b) Each patient file shall include the following information
(2) A complete drug and alcohol history.
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Observations
The facility failed to address progression of drug use in the drug and alcohol history for patients #9 and 10.
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Plan of Correction
Facility Director will be responsible for implementing an updated psychosocial history form for use by counselors. Training will be provided to counselors by Facility Director as to the use of new form and the necessity of addressing drug use progression in completing a history. This will be effective by Oct. 31, 2007
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715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
The facility failed to accurately complete a Mantoux test for tuberculosis for patient #18. The record indicated that the Mantoux test was administered on February 20, 2007 at a local hospital. Information reported to the nurses by the facility director was that patient had been tested on February 22, 2007. The results of the Mantoux test were not read until February 24, 2007 by medical staff instead of the required 48 to 72 hours, thus invalidating the results.
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Plan of Correction
Nursing staff will be instructed to obtain a Mantoux test from all
admissions and readmissions prior to receiving initial dose of methadone. Physician will be responsible for ensuring that patient is seen by nurse to obtain a Mantoux test on admission date. This will be effective immediately.
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715.23(b)(20) LICENSURE Patient records
(b) Each patient file shall include the following information:
(20) Take-home privileges granted to the patient.
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Observations
The facility failed to accurately document patient #18's request for take-home privileges. Documentation in an exception request submitted to the Division stated the reason for the take-home exception was to allow the patient to stay at home with family and a newborn child. The actual documented reason for the take-home dose request stated that patient #18 wanted an extra take home bottle because she wanted to go away. The information submitted to the Division was not complete and accurate.
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Plan of Correction
Facility Director will advise all counselors of incident concerning proper documentation when requesting a dosing exception from the Department. Physician will be responsible for verifying with individual counselor the rationale for seeking exception. This will be effective by Oct. 31, 2007.
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715.23(b)(22) LICENSURE Patient records
(b) Each patient file shall include the following information:
(22) Aftercare plan, if applicable.
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Observations
The facility failed to develop an aftercare plan for patient #7 and 8 that included measurable goals specific to each patient's needs.
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Plan of Correction
Facility Director will be responsible for instructing counseling staff
on the need to include measurable and patient specific goals when creating an aftercare plan. Examples will be shown and discussed during an in house training. This will be effective by Oct. 31, 2007.
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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
A review of patient discharges revealed that the facility failed to specifically address follow-up attempts for discharged patients. Letters contained in the file were undated and lacked patient identifying information including the name of patient. The Division was unable to determine when they were sent or to whom they were sent.
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Plan of Correction
Facility Director will be responsible for updating cover letter used to address follow-up documents to patients. Updated letter will provide
area to place patient name and address, as well as date sent. Facility
Director will be responsible for providing letter to all counseling staff
and instructions on proper utilization. This will be effective by Oct. 31, 2007.
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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
The facility failed to have the medical director sign the annual patient evaluations for # 9 and 19; the medical director signed patient #12's annual evaluation two months late.
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Plan of Correction
Facility Director will be responsible for obtaining from CRNP a list of annual physical examinations for the month. This list will correspond with the necessary clinical annual evaluations that are to be completed by individual counselors. Facility Director will supply physician with patient list for assurance that evaluations are completed and presented in a timely manner. The CRNP will notify counselors of annual dates for patients. The annual evaluations will then be signed by the physician within the one year period. This will be effective Nov. 1, 2007.
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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
The facility failed to develop treatment plans that contained short term goals with action steps. Of thirteen patient charts reviewed for treatment plan content, none contained behavioral tasks that needed to be completed to accomplish the short-term goal(s).
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Plan of Correction
Facility Director will be responsible for ongoing in-services and search
for training materials to assist counselors in the development of
acceptable and realistic treatment plans. This will be effective
immediately, and remain a clinical priority for Director.
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715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
The facility failed to document incident reports regarding two patients who allegedly sold their take-home bottles. The facility director acknowledged receiving three separate reports of this alleged behavior but did not document the incidents as he did not believe the informant.
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Plan of Correction
Facility Director will be responsible for acknowledging all events and
completing an incident report on all events that fall within those
recognized by the Department. Facility Director will forward all incident reports to Compliance Officer for discussion and further action. This will be effective immediately.
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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
The facility failed to provide documentation for a 13 day take-home exception for patient #12. The narcotic treatment physician, via verbal order, placed the patient on a 13 day schedule with no documentation of any emergency justifying a 13 day take-home schedule. There is no evidence that the 13 day take-home exception for patient #12 was submitted to the Department for review and approval.
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Plan of Correction
Physician will be responsible for reviewing the regulations that govern requests for exceptions for take-home doses by the Department. Physician will review and analyze information at the interdepartmental meetings in order to become familiar with rationale for requesting a take home exception from the Department. Facility Director will be responsible for informing physician of this need and the proper documentation. This will be effective by Oct. 31, 2007
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