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 July 8-9, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHJ Medical Center Inc. Vandergrift, 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 and a plan of correction is due on August 8, 2009.
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Plan of Correction
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715.6(a)(2) 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.
(2) When a narcotic treatment program is unable to hire a medical director who meets the qualifications in paragraph (1), the narcotic treatment program may hire an interim medical director. The narcotic treatment program shall develop and submit to the Department for approval a training plan for the interim medical director, addressing the measures to be taken for the interim medical director to achieve minimal competencies and proficiencies until the interim medical director meets qualifications identified in paragraph (1)(i), (ii) or (iii). The interim medical director shall meet the qualifications within 36 months of being hired.
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Observations
Based on a review of the Medical Director qualifications, the facility failed to receive Department approval for a training plan for the medical director.
The findings include:
The Medical Director qualifications were reviewed on July 8, 2009. The Medical Director does not meet the qualifications, therefore is considered an interim medical director. The facility submitted a letter submitted a letter, dated May 18, 2009, to the Department that addressed a staff change, but did not have an approved training plan.
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Plan of Correction
The project director and interim medical director are working to complete a detailed training plan to submit to the department that will enable the medical director to meet the qualifications necessary to comply with this regulation. Once the training plan is completed it will be sent to the department for approval and the submission and approval will be retained in the interim medical directors chart |
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 the narcotic treatment physician hours, the facility failed to document at least 1 hour per week onsite for every ten patients for one of four weeks reviewed.
The findings include:
Four weeks were reviewed on July 9, 2009. The weeks reviewed were May 10, May 17, June 14, and June 28. During the week of June 28, 2009, the facility was required to have 17.4 physician service hours, but only 14 hours of physician services was documented.
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Plan of Correction
Based on current schedules for MD coverage we are currently in compliance for actual coverage, however the project director failed to correctly document the MD hours on the calandar utilized. in the future the project director will ensure that all documentation of MD hours is correctly documented for review by the department. |
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
Based on a review of the patient identification cards and an interview with the facility director, the facility failed to provide a current patient identification card in six of ten records.
The findings include:
Ten patient records were reviewed on July 8-9, 2009. In a conversation with the director, it was reported that it is the facility's policy is to update the patient identification cards annually. In a review of the patient records, seven patient identification cards were expired per the facility policy. Two of the ten expired identification cards were in the patient records (record 13 and 14), one of the ten expired identification cards were reviewed during the dosing observation (records #17), and three cards were randomly chosen from the identification cards kept in the office (18, 19, and 20).
The patient identification card for patient record #13 expired 1-7-09; the card was not updated and the patient was discharged on 3-1-09.
The patient identification card for patient record #14 expired 1-7-09; the card was not updated and the patient was discharged on 4-1-09.
The patient identification card for patient record #17 expired 10-16-08.
The patient identification card for patient record #18 expired 3-7-09.
The patient identification card for patient record #19 expired 1-7-09.
The patient identification card for patient record #20 expired 1-7-09.
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Plan of Correction
The front desk administrator is responsible to ensure taht all client ID cards are not expired. To ensure compliance the front desk administrator has begun to systematically update all expired client ID cards. The front desk administrator has been trained to update all client ID cards when the clients come in for theirannual physical appointment with the medical doctor. New photos will be taken annually and the ID cards will be updated at the annual physical appointment. The project director will randomly sample the client ID cards to ensure continuous compliance with this regulation. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records, the facility failed to document a consult between the Physician,s Assistant and the Physician prior to the physician determining the patient 's initial dose and schedule in one of one patient record.
The findings include:
Sixteen patient records were reviewed on July 8-9, 2009. One record, #1, included a physical examination that was completed by the Physician's Assistant, but did not document a consult with the narcotic treatment physician before the physician determined the patient 's initial dose and schedule.
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Plan of Correction
The project director will discuss this regulation with the Interim Medical director and attending physicians to ensure that proper documentation of this consultation occurs. To ensure continuous compliance the project director will randomly sample intake folders and review the documentation for accuracy. |
715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to document information was sent to the transferring narcotic treatment program in one of one patient record.
The findings include:
Sixteen patient records were reviewed on July 8-9, 2009. One record, #10, did not document the required information that was sent to the facility where the patient transferred.
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Plan of Correction
The primary counselor is responsible to ensure that all transferring documentation is sent to any transferring facility. To ensure compliance the project director will, in the next meeting, remind all staff that the fax transmittal sheet is to be included in the chart for all documentation faxed to any transferring facility as documentation of completion. To ensure continuous compliance charts will randomly be audited and any deficiencies will be noted immediately and any necessary training will be provided. |
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 patient records, the facility failed to ensure that patients were not discharged for reasons other than those listed for involuntary terminations. Documentation in six patient records revealed involuntary terminations for financial reasons was a stipulation provided to the six patients whose records were reviewed. In one of these records, documentation revealed one of these patients was discharged for failure to meet financial obligations.
The findings include:
Sixteen patient records were reviewed on July 8-9, 2009. Six of the records reviewed included a Financial Responsibility form that states, "Payments must be made by Wednesday of the current week or client may be discharged from the program."
Record #2 signed the form on 6-11-09.
Record #3 signed the form on 6-18-09.
Record #4 signed the form on 1-29-09.
Record #5 signed the form on 6-22-09.
Record #9 signed the form on 3-12-09.
Record #16 signed the form on 2-19-09.
In addition, patient record #16 contained documentation of a discharge for financial reasons. Documentation in the patient record included a progress note dated 3-5-09, "Client with no ability to meet financial obligations with a plan for follow-up with inpatient detox or schedule a 7 day detox." A progress note dated 3-10-09 "Client began a 7 day detox due to inability to meet financial obligations." The discharge summary states, "Client denied MA, unable to maintain financial requirements." Additonal record information stated, "Client admitted 2-20-09, VBH pending." Client had 7 day detox starting 3-10-09 client has been discharged, due to inability to meet financial obligations."
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Plan of Correction
The financial responsiblity letter was previously updated and the phrase was removed. However, somehow the old letter ended up in the new client chart master folder. This has been corrected.
In order to ensure proper documentation and continuous compliance the project director will hold a training on discharge procedures and remind the staff of the policies and procedures for client discharge. Following that training the project director or cheif counselor will review of all client discharges, proir to discharge to ensure future compliance with this regualtion. |
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
Based on a review of the patient records, the facility failed to document an annual evaluation in one of six records, and in one of six records the annual evaluation was completed late.
The findings include:
Sixteen patient records were reviewed on July 8-9, 2009. Six records were required to have an annual evaluation documented.
Record # 1, the annual evaluation was due 2-4-09 and was completed 3-12-09.
Record # 6, the annual evaluation was due 4-30-09 and was not documented.
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Plan of Correction
The primary counselor is responsible to ensure that the clients are provided an annual evaluation. To ensure future compliance with this regulation the project director/cheif counselor will hold a meeting to discuss tracking and timeliness of the annual evaluation. Counselors will be reminded of the regulation and provided some recommendations for accuracy in tracking the due dates for the annual evaluation. Random chart audits will be conducted to ensure continuous compliance. |