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 August 20, 2013 to August 22, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House 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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715.6(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 the review of administrative documentation, the facility failed to provide at least one hour of physician time a week, on site, for every ten patients for twelve of twenty-five weeks reviewed.
The findings include:
Physician time sheets for the months of February, March, April, May, June and July 2013 were reviewed on August 20, 2013. Twenty-five weeks were reviewed along with the average census for those weeks. Twelve weeks provided insufficient onsite physician hours during February, March, April, May, June and July 2013.
During the week of February 9 through February 15, 2013, the patient census was 323. The facility was required to provide at least 32.3 physician hours. There were 26.4 physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of February 23 through March 1, 2013, the patient census was 329. The facility was required to provide at least 32.9 physician hours. There were 30.0 physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of March 2 through March 8, 2013, the patient census was 323. The facility was required to provide at least 32.3 physician hours. There were 26.7 physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of March 9 through March 15, 2013, the patient census was 327. The facility was required to provide at least 32.7 physician hours. There were 27.1 physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of March 16 through March 22, 2013, the patient census was 328. The facility was required to provide at least 32.8 physician hours. There were 11.9 physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of April 13 through April 19, 2013, the patient census was 332. The facility was required to provide at least 33.2 physician hours. There were 22.0 physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of April 27 through May 3, 2013, the patient census was 333. The facility was required to provide at least 33.3 physician hours. There were 30.3 physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of May 18 through May 24, 2013, the patient census was 336. The facility was required to provide at least 33.6 physician hours. There were 33.0 physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of May 25 through May 31, 2013, the patient census was 337. The facility was required to provide at least 33.7 physician hours. There were 30.4 physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of June 1 through June 7, 2013, the patient census was 336. The facility was required to provide at least 33.6 physician hours. There were 20.2 physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of June 22 through June 28, 2013, the patient census was 342. The facility was required to provide at least 34.2 physician hours. There were 29.8 physician hours documented. The amount of physician hours documented did not meet the required hours.
During the week of June 29 through July 5, 2013, the patient census was 342. The facility was required to provide at least 34.2 physician hours. There were 27.7 physician hours documented. The amount of physician hours documented did not meet the required hours.
The findings were reviewed with the facility director and confirmed.
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Plan of Correction
715.6(d) Physician Staffing: DHBC will assure that 1 hour of physician time is provided weekly for every 10 patients. A PRN Physician's Assistant will be hired as soon as possible. An ad has been placed to recruit this second PA. Until that hiring occurs DHBC will share current PA resources with DHCU to fill in required hours when current PA is out on leave. This will require signing up the current DHCU PA to work under the DHBC Physician. The Program Director is responsible for completion. |
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
Based on the review of patient records, the facility failed to maintain the confidentiality of all patient records in three of five records reviewed.
The findings included:
Ten patient records were reviewed August 21 - 22, 2013. Five records were reviewed regarding release of information documentation. The facility failed to ensure that an informed and voluntary consent to release information was obtained in three patient records, # 8, 9 and 10.
Patient record # 8 included a consent to release information that contained "release to" and "obtain from" language without differentiating between the two statements. Entities may not release information without written prior consent of the client. Having the two options on the form fails to meet the criteria of informed consent. The federal regulations only have provisions for authorization to disclose information. A consent to obtain information is not consistent with the federal confidentiality regulations found at 42 C.F.R. nor does it authorize a program to disclose information.
Patient record # 9 included documentation of the patient's funding source. The patient record contained a consent to release information that expired May 2013. A current release for the funding source was not documented in the patient record at the time of the review.
Patient record # 10 included documentation of the patient's transfer from another narcotic treatment program. A confirmation of transfer was documented within the patient record. A consent to release the transfer information was not documented in the patient record at the time of the review.
The findings were reviewed with the Clinical Supervisor and confirmed.
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Plan of Correction
715.11 Confidentiality of patient records, 42 CFR 2.22 and 709.28: Internal incident reports have been filed on the violations reported in the license review. In addition disciplinary actions have been written for those staff committing the violations of this regulation.
DHBC will assure current releases, accurately completed, are present prior to any release of information. With patient consent counselors will now complete release forms to expire at the date of discharge or a specific number of days after discharge. A formal training of all clinical staff will be held on September 26, 2013 on the proper way to fill out a release, to check on expired releases and to make sure written consent is in place to release information. Only one way releases are permitted. We will monitor this on a regular basis to ensure accuracy.
The Clinical Supervisor is responsible for training and monitoring.
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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
Based on a review of the patient records, the facility failed to ensure initial and random monthly urinalysis for each patient in two of ten records reviewed.
The findings include:
Ten patient records were reviewed August 21 - 22, 2013. All patient records were required to have random monthly urinalysis. The facility failed to document a random monthly urinalysis in one patient record, #1. Additionally, patient record # 7 failed to document an initial urinalysis.
Patient record # 1 included an admission date of 10/25/2011 and a discharge date of 7/18/2013. The documented urinalysis results were reviewed for the period of September 2012 to June 2013. The patient record contained documentation for 11/20/2012 and 2/13/2013 urinalysis reports that stated Unable To Obtain. A documented urinalysis result was not obtained for these two months.
Patient record # 7 included an admission date of 5/10/2013 with documentation of pregnancy. An initial urine drug screen was documented on 5/31/2013 that was metabolite only.
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Plan of Correction
715.14(a) Urine Testing: The Nurse Manager will check all patient records prior to the initial dosing to assure that the initial urinalysis has been obtained and results reviewed. This will occur whether or not the patient is pregnant. Nurse Manager will also verify during the last week of the month that all patients have provided, or are scheduled for, a UA sample that month. Those showing no sample will be contacted, held for a sample on their next visit and/or scheduled for an NFT. Nurse Manager is responsible to assure completion of the initial as well as monthly UAs. |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on a review of patient records and an administrative review, the facility failed to ensure the narcotic treatment physician documented the review of dosage levels to determine the patient's therapeutic dosage in four of five records reviewed.
The findings included:
Ten patient records were reviewed August 21 - 22, 2013. Five records were reviewed for documentation of the narcotic treatment physician's review of the patient's therapeutic dosage level. Four records failed to document that the narcotic treatment physician had reviewed the patient's dosage, specifically patient records # 1, 2, 4 and 5.
Patient record # 1 contained a service date for a dose review on Thursday, 10/18/2012, that was electronically signed by the narcotic treatment physician on 10/18/2012 at 22:39. The facility's hours end at 13:30 and the narcotic treatment physician hours are documented for Tuesday and Friday. It is unclear based on the documentation that the narcotic treatment physician performed the dose review.
Patient record # 2 contained a service date for a dose review on Thursday, 11/8/2012, at 1 p.m. that was electronically signed by the narcotic treatment physician on Saturday, 11/10/2012 at 22:04. The facility's hours end at 13:30 and the narcotic treatment physician hours are documented for Tuesday and Friday. It is unclear based on the documentation that the narcotic treatment physician performed the dose review.
Patient record # 4 contained a service date for a dose review on Friday, 5/28/2013 at 7 a.m. that was electronically signed by the narcotic treatment physician on Sunday, 6/30/2013 at 19:34. It is unclear based on the documentation that the narcotic treatment physician performed the dose review.
Patient record # 5 contained a service date for a dose review on Friday, 1/11/2013, that was electronically signed by the narcotic treatment physician on Sunday, 1/13/2013. A second dose review with a service date of Wednesday, 7/3/2013, at 12 p.m. was electronically signed by the narcotic treatment physician on Wednesday, 7/31/2013, at 20:42. The facility's hours end at 13:30 and the narcotic treatment physician hours are documented for Tuesday and Friday. It is unclear based on the documentation that the narcotic treatment physician performed the dose review.
The findings were reviewed and confirmed with the Facility Director.
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Plan of Correction
715.15(a) Medication Dosage: The physician will complete all dose reviews as he has been doing. The physician has been advised to sign dose reviews on the date of completion unless there is compelling need to delay signing of the form. The Director will monitor signatures pending on a daily basis to assure timely signatures. The physician will provide to the Director a record of all work hours during each week, regardless of where or when services were provided. The Director will record these hours on the ADP payroll system. The Physician is responsible for completing and signing the dose reviews. The Program Director is responsible for monitoring signatures and dates and entering the correct physician payroll hours. |
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 and an administrative review, the facility failed to ensure that the narcotic treatment physician is determining the proper dosage level for a patient in one of ten records. Additionally, the facility failed to ensure the narcotic treatment physician conducted the patient examination or consulted with the physician completing the patient examination in three of four records reviewed.
The findings included:
Ten patient records were reviewed August 21 - 22, 2013. All records were reviewed for the narcotic treatment physician determining the dosage for the patient. Patient record # 1 failed to document the physician determining the dosage level. Four records were reviewed for initial dose and patient examination. Three records failed to document that the narcotic treatment physician who documented the patient examination determined the initial dose in patient records # 7, 8 and 10. The administrative review noted the narcotic treatment physician was scheduled onsite Tuesday and Friday.
Patient record # 1 included an admission date of October 25, 2011 and a discharge date on July 18, 2013. The patient received an Administrative Withdrawal Notification letter on June 24, 2013 that stated her dose would be decreased by 7.0 mgs per day until 7/14/2013. The narcotic treatment physician signed the letter and documented an order of 5% reduction per day on 6/26/2013.
Patient record # 7 included an admission date of 5/10/2013 with an initial dose on 5/11/2013 at 7:24 a.m. A patient examination with a service date of Friday, 5/10/2013, with a plan to admit the patient at 30 mg, was electronically signed by the narcotic treatment physician on Friday, 5/24/2013 at 13:08. A dosing order was electronically signed on Saturday, 5/11/2013, at 7:20 a.m. for a starting dose of 25 mg. It is unclear based on the documentation if the narcotic treatment physician who performed the patient examination determined the initial dose.
Patient record # 8 included an admission date of 7/12/2013 with an initial dose on 7/12/2013 at 10:22 a.m. as a transfer from another narcotic treatment program. A patient examination with a service date of Friday, 7/12/2013, with a plan to start the patient at 84 mg, was electronically signed by the narcotic treatment physician on Tuesday, 7/30/2013 at 08:32. It is unclear based on the documentation if the narcotic treatment physician who performed the patient examination determined the initial dose.
Patient record # 10 included an admission date of 7/29/2013 with an initial dose on 7/29/2013 at 6:38 a.m. A patient examination with a service date of Friday, 7/26/2013, at 10 a.m., was electronically signed by the narcotic treatment physician on Wednesday, 7/31/2013, at 21:53. An order was documented on Sunday, 7/28/2013, to admit the patient at 65 mg. It is unclear based on the documentation if the narcotic treatment physician who performed the patient examination determined the initial dose.
The findings were reviewed and confirmed by the Facility Director.
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Plan of Correction
715.15(b) Medication Dosage: The program Physician will complete and sign the initial dose at admission on the day of admission. The signature will be completed at the clinic. This complies with the regulations and with company policy which states that the Physician will sign approval of the dosage prior to any methadone being dispensed.
We will hold training on September 26, 2013 with all clinical staff on the correct way to initiate an Administrative Withdrawal notice. We will monitor completion of these forms on a regular basis to ensure accuracy. After counselors complete their section of the form, the Physician will complete the milligrams of dose reduction and end date. The Physician will sign these forms only on days at clinic, which are currently Tuesday and Friday.
The Physician is responsible for completing and signing initial dose orders. The Clinical supervisor is responsible for training counseling staff on completion of Administrative Withdrawal forms and monitoring completion of those forms.
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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
Based on a review of patient records and an administrative review, the facility failed to ensure the narcotic treatment physician documented in the patient record the rationale for granting take home medication in five of five patient records.
The findings included:
Ten patient records were reviewed August 21 - 22, 2013. Five records were reviewed for take home medication documentation, # 4, 7, 8, 9 and 10. The administrative review noted the narcotic treatment physician was scheduled onsite Tuesday and Friday.
Patient record # 4 identified an admission date of 6/3/2009 and a discharge date of 8/6/2013. The patient record contained documentation of a 6-day take home schedule on Tuesday, 1/29/2013. The narcotic treatment physician's documentation noted "per counselor and MDT (multidisciplinary team), the patient has been granted home dosing privileges. I approve." The narcotic treatment physician documentation did not address the rationale for permitting take home medication.
Patient record # 7 identified an admission date of 5/10/2013. The patient record contained documentation of weekend (Saturday and Sunday) take home schedule on Wednesday, 8/14/2013. The narcotic treatment physician's documentation noted "per counselor and MDT (multidisciplinary team), the patient has been granted home dosing privileges. I approve this action." The documentation of approval and the 8 point criteria were electronically signed on 8/14/2013 at 21:34. The narcotic treatment physician documentation did not address the rationale for permitting take home medication.
Patient record # 8 identified an admission date of Friday, 7/12/2013, with three take home bottles per week. The narcotic treatment physician documented via electronic signature on 7/12/2013 at 10:01 the patient was a transfer from another narcotic treatment program. The documentation continued "per counselor and MDT (multidisciplinary team), the patient has been granted continued home dosing privileges. I approve this action." Additionally, the patient record contained documentation of twice weekly facility attendance on Tuesday, 8/20/2013. On 8/20/2013 at 22:14 via electronic signature, the narcotic treatment physician documentation noted "per counselor and MDT (multidisciplinary team), the patient has been granted continued home dosing privileges. I approve this action." The narcotic treatment physician documentation did not address the rationale for permitting take home medication.
Patient record # 9 identified an admission date of 5/19/2010. The patient record contained documentation of twice weekly facility attendance via electronic signature on Monday, 7/8/2013 at 19:49. The narcotic treatment physician's documentation noted "per counselor and MDT (multidisciplinary team), the patient has been granted home dosing privileges. I approve this action." The narcotic treatment physician documentation did not address the rationale for permitting take home medication.
Patient record # 10 identified an admission date of 7/29/2013. The patient record contained documentation of 6-day take home bottles via electronic signature on 7/29/2013 at 16:07. The narcotic treatment physician's documentation noted "patient is direct transfer from (another narcotic treatment facility) with no break in treatment. Patient is transferring with 6-day status take home privileges." The narcotic treatment physician documentation did not address the rationale for permitting take home medication.
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Plan of Correction
715.16(a)(3) Take-home privileges:
The Program Director has provided counseling to the program Physician regarding the need to document rationale for take home privileges. The Physician will clearly state the rationale for granting take home medication on the order. The Physician will refer to the 8 points form if additional details as to the rationale are needed. The Physician is responsible for assuring completion of the rationale prior to granting take home privileges to a patient. The Director is responsible for monitoring completion of this documentation.
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715.16(c)(2)(i-iv) LICENSURE Take-home previliges
(c) A narcotic treatment program shall require a patient to come to the narcotic treatment program for observation daily or at least 6 days a week for comprehensive maintenance treatment, unless a patient is permitted to receive take-home medication as follows:
(2) A narcotic treatment program may permit a patient to reduce attendance at the narcotic treatment program for observation to two times weekly and receive no more than a 3-day take-home supply of medication when in the reasonable clinical judgment of the narcotic treatment physician, which is documented in the patient record:
(i) A patient demonstrates satisfactory adherence to narcotic treatment program rules for at least 2 years.
(ii) A patient demonstrates substantial progress in rehabilitation.
(iii) A patient demonstrates responsibility in handling narcotic drugs.
(iv) A patient demonstrates that rehabilitation progress would improve by decreasing the frequency of attendance for observation.
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Observations
Based on a review of patient records, the facility failed to ensure all patients demonstrated satisfactory adherence to the narcotic treatment program rules for reduced attendance to two times weekly in one of two patient records reviewed.
The findings included:
Ten patient records were reviewed August 21 - 22, 2013. Two records were reviewed for twice weekly program observation.
Patient record # 8 identified an admission date of Friday, 7/12/2013, with three take home bottles per week. The patient record contained documentation of twice weekly facility attendance on Tuesday, 8/20/2013. On 8/20/2013 at 22:14 via electronic signature, the narcotic treatment physician documentation noted "per counselor and MDT (multidisciplinary team), the patient has been granted continued home dosing privileges. I approve this action." The patient record did not contain the documentation of at least two years of the required information as the patient was recently admitted and the information was not received from the previous narcotic treatment program.
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Plan of Correction
715.16(c)(2)(i-iv) Take-home privileges:
Clinical staff will assure that all needed information is obtained and reviewed in the 8 point form prior to clinic action on take homes. The paperwork will contain information showing patient's satisfactory adherence to all applicable narcotic treatment program rules. Training for clinical staff will be conducted by September 26, 2013, regarding what information we need when we receive a transfer patient who already has their take home privileges prior to us granting them take homes. Clinical supervisor/ senior counselor will follow up to make sure the correct documentation is in the patient's chart prior to granting take homes. The Clinical Supervisor is responsible for training clinical staff and assuring accuracy of the 8 point form. The physician is responsible for reviewing and signing the 8 point and orders granting take homes.
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715.16(c)(3)(i-viii) LICENSURE Take-home privileges
(c) A narcotic treatment program shall require a patient to come to the narcotic treatment program for observation daily or at least 6 days a week for comprehensive maintenance treatment, unless a patient is permitted to receive take-home medication as follows:
(3) A narcotic treatment program may permit a patient to reduce attendance at the narcotic treatment program for observation to one time weekly and receive no more than a 6-day take-home supply of medication when in the reasonable clinical judgment of the narcotic treatment physician, which is documented in the patient record:
(i) A patient demonstrates satisfactory adherence to narcotic treatment program rules for at least 3 years.
(ii) A patient demonstrates substantial progress in rehabilitation.
(iii) A patient demonstrates responsibility in handling narcotic drugs.
(iv) A patient demonstrates that rehabilitation progress would improve by decreasing the frequency of attendance for observation.
(v) A patient demonstrates no major behavioral problems.
(vi) A patient is employed, is actively seeking employment, attends school, is a homemaker or is considered unemployable for mental or physical reasons.
(vii) A patient is not known to have abused alcohol or other drugs within the previous year.
(viii) A patient is not known to have engaged in any criminal activity within the previous year.
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Observations
Based on a review of patient records, the facility failed to ensure all patients demonstrated satisfactory adherence to the narcotic treatment program rules for reduced attendance to one-time weekly in one of two patient records reviewed.
The findings included:
Ten patient records were reviewed August 21 - 22, 2013. Two records were reviewed for one-time weekly program observation.
Patient record # 4 identified an admission date of 6/3/2009 and a discharge date of 8/6/2013. The patient record contained documentation of a 6-day take home schedule on Tuesday, 1/29/2013. The narcotic treatment physician's documentation noted "per counselor and MDT (multidisciplinary team), the patient has been granted home dosing privileges. I approve." The patient record documented urinalysis results positive for opiates on 9/20/2012, 9/21/2012, 10/24/2012, 11/27/2012, 12/20/2012 and 1/11/2013. The positive urine screens were not addressed in the patient record.
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Plan of Correction
715.16(c)(3)(i-viii) Take-home privileges:
We will assure that all needed paperwork is completed and reviewed prior to clinic action on take homes. The paperwork will contain information showing patient's satisfactory adherence to all applicable narcotic treatment program rules. Training for clinical staff will be held on or before September 26, 2013, regarding what information we need prior to granting take homes when we receive a transfer patient who already has take home privileges. Clinical supervisor/ senior counselor will follow up to make sure the correct documentation is in the patient's chart prior to granting take homes. The Clinical Supervisor is responsible for ensuring the team is presented with correct and complete information.
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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
Based on a review of patient records, the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment in two of five records.
The findings included:
Ten patient records were reviewed August 21 - 22, 2013. Five records were reviewed for psychotherapy hours during the first 2 years of treatment. The facility failed to ensure that the patient received a minimum of 2.5 hours of psychotherapy in patient records # 2 and 3.
Patient record # 2 identified an admission date of November 9, 2011 and a discharge date of July 22, 2013. During the months of April 2013, May 2013 and June 2013, the patient received an average of 2 psychotherapy hours. The patient record documented 3 psychotherapy hours for the month of April, 2 hours for May, and 1 hour for June.
Patient record # 3 identified an admission date of August 28, 2012 and a discharge date of May 31, 2013. During the months of March 2013, April 2013 and May 2013, the patient received an average of 2.25 psychotherapy hours. The patient record documented no psychotherapy hours for the month of March as the patient was at an inpatient facility, 3 psychotherapy hours for April, and 1.5 hours for May.
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Plan of Correction
715.19(1) Psychotherapy services:
If the pt does not meet the required psychotherapy hours one month the patient will need to make it up the next month and meet the standard average over a three month period. If the patient continues to fail to complete required hours, the counselor will place the patient on a treatment agreement assigning the patient a range of dosing hours, which means the patient must meet for counseling prior to dosing.
In terms of procedure, by the first week of the following month each counselor will review with their supervisor all assigned patients under two years in service who failed to meet their average monthly hours during the previous months. A treatment plan revision or treatment agreement will be developed for review with the patient that will address the failure to meet service hours. The Clinical Supervisor is responsible for implementing this change.
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715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to provide each patient at least 1 hour of psychotherapy per month during the patient's third and fourth year of treatment in one of two records.
The findings included:
Ten patient records were reviewed August 21 - 22, 2013. Two records were reviewed for psychotherapy hours during the third and fourth year of treatment.
Patient record # 5 identified an admission date of July 14, 2010. The patient record contained documentation of 1 hour of psychotherapy during June 2013 and August 2013. The record noted the patient failed to show for a scheduled psychotherapy session in July 2013. The record lacked documentation of an attempt to address the missed session.
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Plan of Correction
715.19(2) Psychotherapy services:
If the pt does not meet the required psychotherapy hours for a month the patient will need to make it up the next month. If the patient continues to fail to complete required hours, the counselor will place the patient on a treatment agreement assigning the patient a range of dosing hours, which means the patient must meet for counseling prior to dosing.
In terms of procedure, by the first week of the following month each counselor will review with their supervisor all assigned patients between two and four years in service who failed to meet their monthly hours during the previous month. A treatment plan revision or treatment agreement will be developed for review with the patient that will address the failure to meet service hours. The Clinical Supervisor is responsible for implementing this change.
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715.20 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.
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Observations
Based on a review of patient records, the facility failed to initiate a transfer within 7 days of the patient request in two of two patient records reviewed.
The findings include:
Ten patient records were reviewed August 21 - 22, 2013. Two records were reviewed for transfer documentation within 7 days of the patient request, # 3 and 4.
Patient record # 3 contained a consent to release information to the receiving narcotic treatment program signed by the patient on 5/23/2013. The documentation of the information submitted to the receiving narcotic treatment program was dated 6/2/2013. This was 10 days after the patient request.
Patient record # 4 contained a consent to release information to the receiving narcotic treatment program signed by the patient on 7/19/2013. The documentation of the information submitted to the receiving narcotic treatment program was dated 7/30/2013. This was 11 days after the patient request.
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Plan of Correction
715.20 Patient Transfers:
Counselors will be trained September 26, 2013 on the details of transfers out of the program to other MMT programs, including the requirement to complete the transfer within seven days. The Clinical Supervisor or Senior Counselor will meet with counselors who are working to assist patients in transferring in order to assure compliance with requirements. Counselors will initiate the transfer immediately after the pt's request. Clinical supervisor/senior counselor will follow up to ensure that this gets completed. The Clinical Supervisor is responsible for training and correct implementation of the transfer process.
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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
Based on the review of patient records, the facility failed to restrict the reasons for involuntary termination to those allowed by regulation in two of four discharge patient records.
The findings include:
Ten patient records were reviewed August 21 - 22, 2013. Four patient records were reviewed for discharge. Two patient records contained documentation of the patient being discharged for reasons other than those listed by regulation.
Patient record # 1 identified an admission date of October 25, 2011 and a discharge date of July 18, 2013. The patient received an Administrative Withdrawal Notification letter on June 24, 2013 that stated she was being discharged for failing to "become fully invested in her recovery as evident by countless missed counseling sessions, failure to recognize the seriousness of her addiction and admit she is an addict, 12 positive u/a's and struggle to make consistent progress with her treatment goals. Over the last 6 months alone patient has failed to become fully invested in her treatment progress, as evident by her failure to work on and demonstrate progress with her treatment plan goals, her accumulation of 17 no call/no shows for individual and group treatment sessions, failure to comply with treatment agreements and 4 positive u/a's." The patient record did not document attempts to engage the patient following failed session attendance. Although the patient had numerous session absences, the treatment plan objective was to attend 2.5 hours of counseling per month. The average attendance for January 2013, February 2013, March 2013, April 2013, May 2013 and June 2013 was 2.67 counseling hours.
Patient record # 3 identified an admission date of August 28, 2012 and a discharge date of May 31, 2013. The patient received a Treatment Agreement on 5/22/2013 regarding providing positive urine drug screens. A multidisciplinary team meeting was held on 5/17/2013 that led to the Treatment Agreement. On 5/23/2013, the patient was informed by the counselor that he would be discharged due to a positive drug screen that was provided on 5/16/2013 prior to the Treatment Agreement. The patient record did not include documentation of attempts to engage the patient following a positive urinalysis result.
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Plan of Correction
715.21(1)(i-iv) Patient termination:
Counselors will be trained on the details of involuntary terminations. This training will occur on September 26, 2013, and will include the reasons for involuntary termination that are allowed by regulations. Clinical staff will document what they have done and what the patient has done to promote successful recovery. This documentation will be completed in ongoing notes as well as at the time of termination. Clinical staff will use recovery oriented language in their documentation. The Clinical Supervisor or Senior Counselor will meet with counselors who are working on involuntary termination situations in order to assure compliance with these requirements.
The Clinical Supervisor is responsible for training and correct implementation of involuntary terminations.
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715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of patient records and an administrative review, the facility failed to ensure the narcotic treatment physician who conducted the patient annual examination and the inclusion of the annual reevaluation signed the documentation in five of five patient records reviewed.
The findings included:
Ten patient records were reviewed August 21 - 22, 2013. Five records were reviewed for annual examination with reevaluation. The administrative review noted the narcotic treatment physician was scheduled onsite Tuesday and Friday.
Patient record # 1 contained an annual physical with a service date of Thursday, 10/18/2012, that was electronically signed by the narcotic treatment physician on 10/18/2012 at 22:41. The facility's hours end at 13:30 and the narcotic treatment physician hours are documented for Tuesday and Friday. It is unclear based on the documentation that the narcotic treatment physician who signed the annual physical examination performed the examination.
Patient record # 2 contained an annual physical with a service date of Friday, 11/9/2012, that was electronically signed by the narcotic treatment physician on Saturday, 11/10/2012, at 22:04. Additionally, the annual reevaluation with a service date of Thursday, 11/8/2012, at 1 p.m. was electronically signed by the narcotic treatment physician on Saturday, 11/10/2012 at 22:04. The facility's hours end at 13:30 and the narcotic treatment physician hours are documented for Tuesday and Friday. Upon review of the documentation of the annual physical, content was found to be missing, specifically the vital signs were not documented. It is unclear based on the documentation that the narcotic treatment physician performed the dose review.
Patient record # 4 contained an annual physical with a service date of Friday, 5/28/2013, that was electronically signed by the narcotic treatment physician on Sunday, 6/30/2013, at 19:33. Additionally, the annual reevaluation with a service date of Friday, 5/28/2013 at 7 a.m. was electronically signed by the narcotic treatment physician on Sunday, 6/30/2013 at 19:34. It is unclear based on the documentation that the narcotic treatment physician performed the dose review.
Patient record # 5 contained an annual physical with a service date of Friday, 7/12/2013, that was electronically signed by the narcotic treatment physician on Wednesday, 7/31/2013, at 20:41. Additionally, the annual reevaluation with a service date of Wednesday, 7/3/2013, at 12 p.m. was electronically signed by the narcotic treatment physician on Wednesday, 7/31/2013, at 20:42. The facility's hours end at 13:30 and the narcotic treatment physician hours are documented for Tuesday and Friday. It is unclear based on the documentation that the narcotic treatment physician performed the dose review.
The findings were reviewed and confirmed by the Facility Director. An interviewed employee confirmed performing the physicals.
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Plan of Correction
715.23(b)(5) Patient Records:
The physician will provide to the Director a record of all work hours during each week, regardless of where or when services were provided. The Director will record these hours on the ADP payroll system. The physician will also sign dose reviews and annual exams and evaluations at the clinic, on the date of completion, unless there is compelling need to delay signing of the form. The Physician is responsible for implementation. The Director is responsible for monitoring.
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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
Based on a review of patient records, the facility failed to ensure an aftercare plan was documented in two of three patient records reviewed.
The findings included:
Ten patient records were reviewed August 21 - 22, 2013. Three patient records were reviewed for an aftercare plan.
Patient record # 1 identified an admission date of October 25, 2011 and a discharge date of July 18, 2013. An aftercare plan was documented at the time of annual review on 10/10/2012. The aftercare plan was not updated for current information at the time of discharge.
Patient record # 2 identified an admission date of November 9, 2011 and a discharge date of July 22, 2013. An aftercare plan was documented at the time of annual review on 11/5/2012. The aftercare plan was not updated for current information at the time of discharge.
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Plan of Correction
715.23(b)(22) Patient records:
Review of aftercare planning requirements with counseling staff, including the need for an update of the plan at discharge, was completed on September 12, 2013. Clinical staff and the patient will develop a new or revised after care plan on the patient's last day. The Clinical Supervisor will review all aftercare plans at discharge to assure compliance. The Clinical Supervisor is responsible to assure completion of this plan of correction.
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709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on a review of patient records, the facility failed to ensure that verbal medication orders are signed within 24 hours by the prescribing physician in one of two patient records.
The findings include:
Ten patient records were reviewed August 21 - 22, 2013. Two patient records contained documentation of a verbal medication order. A verbal medication order was not signed by the prescribing physician within 24 hours in patient record # 2.
Patient record # 2 identified an admission date of November 9, 2011 and a discharge date of July 22, 2013. A verbal medication order, received by nursing on 7/3/2013 at 07:21, was signed by the prescribing physician on 7/4/2013 at 22:01.
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Plan of Correction
709.32(b) Medication control:
The program Physician has been instructed by the program Director to review and sign all verbal orders within 24 hours. Payroll hours will be recorded for the days that work is completed. If digital glitches occur that prevent electronic signing within 24 hours, the Physician will sign a printed paper copy of the order which will then be filed in the patient record. The Physician is responsible for implementing this plan and the Director is responsible for monitoring implementation.
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