INITIAL COMMENTS
|
This report is a result of an on-site inspection conducted for the approval to use a narcotic agents methadone and buprenorphine in the treatment of narcotic addiction. This inspection was conducted on May 28 and 29, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Aldie Counseling Center. 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 June 25, 2008.
|
Plan of Correction
|
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
|
Observations
Based on the review of administrative documentation, as well as staff interviews, the facility failed to ensure sufficient physician hours for every ten patients during the following weeks: week of 12/31/07 - 5 hours, 99 patients; 02/11/08 - 4.5 hours, 112 patients; and 02/18/08 - 6.5 hours, 114 patients. The patient census currently is 117. Over the period of time reviewed, the physician hours were less than required based the patient census.
|
Plan of Correction
Currently we have 3 Narcotic Treatment Physicians in place. Two of our Narcotic Treatment Physicians are providing 14 hours of dedicated Pharmacotherapy hours. Our 3rd Narcotic Treatment Physician/ Psychiatrist, provides Psychiatric services to our Pharmacotherapy clients during his 10 hours per week and is available for coverage in the absence of this dedicated time. Beginning in September our dedicated Narcotic Treatment Physician hours are contracted to increase from 14 to 22, which will allow for the continued growth of the program to the licensed capacity/ Physician ratio.
Program Coordinator will maintain oversight and insure compliance with the ratio of Narcotic Treatment Physician hours to current census on a weekly basis. In addition Aldie will identify a clear system to document Narcotic Treatment Program physician time based on direct work or time dedicated to NTP chart review, face to face time and staff consultation, etc.
|
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.
|
Observations
Based on the review of sixteen patient records, six of six of the patient records reviewed for this standard failed to include documentation of the physician's basis for determination of current and at least one year history of addiction. Rather there was a standard statement of determination at the end of the physical exam for each of the six patients, # 2, 3, 4, 8, 14, and 16. In addition, all six records reviewed had "yes" written in the section that listed withdraw signs and symptoms without specifying those that were specific to each patient.
|
Plan of Correction
Narcotic Treatment Physician will fully evaluate, prior to admission, all clients and all documentation on every candidate presenting for admission to the Pharmacotherapy Program to determine current and at least one year history of addiction. The Narcotic Treatment Physician's determination will be documented and placed in the client's record along with his physical examination paperwork. The physical examination will note current specific withdrawal symptoms, specific to each patient. A positive urine drug screen at admission can be used as part of this documentation, but will not be the only basis for determining dependency. The Program Coordinator will review all new admission records weekly to assure this process is followed consistently.
|
715.10(c) LICENSURE Pregnant patients
(c) Counseling records and other appropriate patients records shall reflect the nature of prenatal support provided by the narcotic treatment program.
|
Observations
Based on a review of 16 patient records, the facility failed to document in one of one records applicable for this standard that the patient received any prenatal support by the program, patient record #4.
|
Plan of Correction
A questionnaire/checklist form will be created and implemented with all pregnant client admissions. It will include: current prenatal care being received and by whom, possible referrals for prenatal care and agencies referred to, and prenatal care provided by Aldie. This questionnaire will be completed at orientation by the Program Coordinator, signed and dated by the client and the Program Coordinator, and provided to the Primary Therapist assigned for ongoing oversight, review and updates. Upcoming trainings will be scheduled with MOMS and Family Center to further support this. Initial phase of the Plan to be implemented by 6/30/08. |
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).
|
Observations
Based on the review of 16 patient records, six of eight records applicable to the standard failed to adhere to confidentiality requirements in the following manner: patient record #1 contained two consents to release information that were signed by the patient and a witness, but the remaining information was blank; record # 2 contained a first and last name of another patient; in records # 2 and 13, the patients' medication information was released to the Social Security Disability Agency; records # 6 and 7 both contained lists with other patient's first and last names; record # 14 failed to identify the recipient of the information and that entity's or person's relationship to the patient.
|
Plan of Correction
All Clinical Staff will be trained in the proper completion of releases. Administrative Support Staff will be trained in proper record keeping practices and filing of client paperwork. Program Coordinator will be responsible for quarterly 100% review of all Pharmacotherapy records, in addition to random record reviews to assure maintenance of confidentiality. In addition, Program Coordinator will provide proactive supervision with clinicians and Administrative Support Staff.
|
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.
|
Observations
Based on the review of 16 patient records, the facility failed to ensure at least a monthly urinalysis for one of eight records reviewed for the applicable standard.
|
Plan of Correction
Current random urine drug screens are initiated electronically. The AMS system includes a check box feature that insures scheduling of randomly selected urines. Moving forward, the Nurse Manager will run a weekly report prior to the weekly run of the urine test labels to cross check against this feature to determine that all clients have been assigned to a urine screen schedule. |
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.
|
Observations
Based on the review of 16 patient records, the facility failed to adhere to the standard by granting take-home medications to one of seven applicable patient records. Patient record # 3 contained documentation of the last five urine drug screens being positive for alcohol and several screens since May 6, 2008 being negative for creatinine, the test for urine validity. The patient failed to meet the minimal requirements for take-home privileges.
|
Plan of Correction
A case consult will be conducted with each take-home request at the weekly Treatment Team meeting. Each case consult will specifically identify adherence to the 8 criteria necessary to grant a take-home. Included in this will be attention to presence or absence of positive and/or irregular drug screens. Narcotic Treatment Physician will document on every take-home request form, their rationale for permitting that take-home medication. In addition, all drug screen results will be reviewed by the Program Coordinator, Medical Director and Primary Therapist on a weekly basis. Presence of irregular drug screens, secondary to previously granted take-homes, will similarly results in a case consult to determine loss of take-homes. |
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.
|
Observations
Based on the review of 16 patient records, the facility failed to ensure a case consultation was documented in one of seven records reviewed, # 3.
|
Plan of Correction
All changes to a clients privileges (ie:approving take-home medications, etc) will be fully discussed during the weekly Treatment Team Meeting and documented with a new Physician Order - including the Medical Directors rationale regarding approval, and Case Consult noting comments/concerns from Team Members. The Program Coordinator will review the request for appropriateness before signing off on the Case Consult. The Program Coordinator will review client records during routine quarterly QA record review to ensure the inclusion of a case consultation is present in all the records |
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.
|
Observations
Based on the review of the facility policy and procedure manual, the facility exceeded what is permitted by regulation by stating emergency take home medications may be given without meeting other requirements as long as the emergency is "well-documented". In addition, the policy states that only 30 days of negative urine drug screening results are necessary for approval of an exception.
|
Plan of Correction
Written policy and procedure was changed by the Quality Assurance Officer to reflect that the consideration of emergency take-home medications does not preclude assurance that State and Federal requirements are met. The Pharmacotherapy Coordinator will provide training to the clinical staff regarding the policy change and provide oversight to assure adherence. |
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.
|
Observations
Based on the review of 16 patient records, the facility failed to adhere to this standard in one of nine applicable records reviewed. In patient record # 2, the patient was admitted in September 2007 and discharged in April 2008 as non-compliant. Patient was placed on a contract that was to have been in place until 6-1-08, but the program terminated the patient prior to the end of the contract. Record documentation showed that the patient struggled with missing dosing and counseling sessions as well as using illicit drugs, but the patient's treatment plan did not include these problem areas specific to this patient. Therefore, an involuntary termination was initiated without demonstration that all possible efforts to engage or retain the patient in treatment were attempted prior to termination.
|
Plan of Correction
Program Coordinator will provide training on policy regarding involuntary terminations. Moving forward, all terminations will be reviewed at the Treatment Team Meeting as a case consult to determine that all efforts to engage or retain the patient in treatment were attempted prior to termination. Approval will be signed off by the Medical Director and Program Coordinator. |
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.
|
Observations
Based on the review of the facility policy and procedure manual and chart documentation of an orientation form signed by patients, the facility failed to restrict the policy and procedure on patient termination to the reasons permitted by regulation. The facility documentation stated that a second falsification of urine drug screen is a reason for an administrative (involuntary) detoxification.
|
Plan of Correction
Written Policy and Procedure was changed by the Quality Assurance Officer to reflect the Federal and State regulatory limitations for involuntary termination. Policy regarding falsification of urine drug testing will now reflect behavioral and treatment sanctions excluding involuntary termination.
The Pharmacotherapy Coordinator will provide training to the clinical staff on the policy change and ensure oversight that the policy is adhered to
|
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.
|
Observations
Based on the review of 16 patient records, one of four applicable records reviewed was missing a blood serology (# 8), and in the other patient record, the blood serology was obtained more than one month after admission (# 14).
|
Plan of Correction
All clients will be scheduled for blood serology at the time of orientation to be conducted within one week of admission. Program Coordinator will now utilize a check list for scheduled lab appointments each week to ensure identification that all lab work is completed. Those clients identified as not having attended scheduled lab work will be monitored by the Coordinator for compliance within the required one month time frame. Ongoing documentation regarding efforts to bring the client into compliance with lab work will be maintained in the client record by the Program Coordinator. |
715.23(b)(11) LICENSURE Patient records
(b) Each patient file shall include the following information:
(11) Counselor notes regarding patient progress and status.
|
Observations
Based on review of 16 patient records, the facility failed to provide the required information regarding the patient's progress and status in the clinical notes in five of six applicable records reviewed, # 3, 8, 9, 13, and 16. The Data, Assessment, Plan (DAP) format was utilized. The "D" (data) did not address information regarding the progress and status related to the established treatment plan. The "A" (assessment) failed to consistently provide a clinical assessment of the patient's progress and the "P" (plan) focused on the date of the next session instead of the required future strategies that the patient was to do based on the context of the treatment plan and the content of the work done in the counseling session. In addition, the last progress note written for #9 was 2-27-08 and the last written progress note for # 16 was 12-10-07.
|
Plan of Correction
Program Coordinator will train all clinicians in the proper use of the DAP format, insuring through supervision and quarterly review of charts that the necessary information is documented in progress notes. |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
|
Observations
Based on review of 16 patient records, the facility failed to provide an evaluative assessment of the historical data obtained that included the counselor's clinical analysis of the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, patient's attitude toward treatment and overall impressions. Instead, the psychosocial evaluations of the patient consisted primarily of the repetition of the history and statements reported by the patient in four of five records reviewed, # 3, 4, 14, and 16. The evaluation in record # 8 was illegible, therefore, the content could not be reviewed.
|
Plan of Correction
The Program Coordinator will provide training, ongoing quality review, and supervision regarding the need to synthesize the factual information gathered in intake into a clinical evaluation of assets/strengths/support systems and coping mechanisms etc., as well as the required time frames for completion of this document.
Specific attention will be paid to the assessment of clinical data. This clinical assessment will be reviewed by the Program Coordinator for content and legibility before being cosigned and placed in clients chart. In addition, concurrent peer chart review will be conducted monthly with random sampling of currently active client records.
|
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
|
Observations
Based on a review of 16 patient records, the facility failed to document a complete discharge summary in four of six applicable records, specifically #1, 2, 5, and 7. The discharge summary in records # 2 and 7 failed to document the patient's reason for treatment. Records # 1, 2, and 5 failed to include documentation in the discharge summary about the patient's progress in treatment.
|
Plan of Correction
The Program Coordinator will train clinical staff on discharge procedures with specific attention to appropriate time-frames for completion and necessary documentation including such items as motivation and progress in treatment. A monthly discharge report will be reviewed and monitored by the Program Coordinator for timely completion of discharges and all discharges will be reviewed prior to co-signing by the Program Coordinator for accurate completion of all documentation. |
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.
|
Observations
Based on the review of 16 patient records, two of two applicable records, # 9 and 13, failed to evaluate the patient's status, but rather contained check boxes that contained limited content and did not provide an annual evaluation.
|
Plan of Correction
The Program Coordinator will provide further training for clinicians who are utilizing this Annual Evaluation form for the first time, in order to assure a complete record/view of clients' current status within the program relating to their continued recovery which provides content and evaluation.
|
715.23(d) 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.
|
Observations
Based on the review of 16 patient records, four of five applicable records, # 2, 3, 8, and 14, contained treatment plans with global and non-specific goals; the contents did not address patient specific needs and goals as identified in patients' personal histories and psychosocial evaluations. One was missing a comprehensive treatment plan, #16,
|
Plan of Correction
The Program Coordinator will provide an in-service to all Pharmacotherapy Counselors on proper Treatment Plan development. The in-service will include: how to write specific, easy to understand steps to reach the identified goals, the identification and incorporation of external supports, and how to individualize time-frames for completion of those steps (objectives). In-service to take place in group supervision scheduled 6/26/08. The Program Coordinator will continue to maintain quarterly review of clinical records for completeness specific to this corrective action plan. In addition, concurrent peer chart review will be conducted monthly with a random sampling of currently active client records.
The agency is also about to embark on a year-long training program and research collaboration with TRI (Treatment Research Institute) with focusing on improvement in the quality and effectiveness of treatment plans. The program will focus on identification of observable measurable goals with specific links to supports for identified problem areas. Clinicians will be receiving 8 hours of CAC training from TRI specific to this initiative.
|
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.
|
Observations
Based on the review of 16 patient records, five of six applicable records contained non-measurable, non-specific steps to reach the goals and the time frames were generalized rather than realistically specific to the action step. Further, the treatment plans did not include support services. The records reviewed were # 3, 8, 13, 14, and 16.
|
Plan of Correction
The Program Coordinator will provide an in-service to all Pharmacotherapy Counselors on proper Treatment Plan development. The in-service will include; how to write specific, easy to understand steps to reach the identified goals, the identification and incorporation of external supports, identification of behavioral tasks the client shall perform, and how to individualize time frames for completion of those steps (objectives). In-service to take place in group supervision scheduled 6/11/08. The Program Coordinator will continue to maintain quarterly review of clinical records for completeness specific to this corrective action plan. In addition, concurrent peer chart review will be conducted monthly with a random sampling of currently active client records.
The agency is also about to embark on a year-long training program and research collaboration with TRI (Treatment Research Institute) with focusing on improvement in the quality and effectiveness of treatment plans. The program will focus on identification of observable measurable goals with specific links to supports for identified problem areas. Clinicians will be receiving 8 hours of CAC training from TRI specific to this initiative.
|
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.
|
Observations
Based on review of administrative documentation provided during the inspection and staff interviews, the facility failed to submit documentation of unusual incidents to the Department as required. Incidents included drug-related hospitalization of patients and incidents with the potential for negative community reaction.
|
Plan of Correction
Aldie's Unusual or Critical Incident Reporting Policy was reviewed at Aldie Administrative meeting, secondary to the annual QA review on 6/4/08. In addition, all staff were retrained on incident reporting policy specific to what areas were to be reported to the Department of Health including incidents involving drug-related hospitlizations and incidents with the potential for negative community reaction. Coordinators will review all incident reports within 24 hours to determine compliance with Department of Health reporting requirements. |