INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use a narcotic agents, specifically methadone and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on January 10, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, A.R.S. of Lancaster, L.P. 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 February 9, 2011.
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Plan of Correction
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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
Based on the review of patient records and an interview with the facility director, the facility failed to contact the previous narcotic treatment facility for the patient's treatment history in three of three patient records reviewed, as required.
The findings include:
Twenty-four patient records were reviewed January 10-13, 2011. Three patient records required contacting the prior narcotic treatment facility for the previous treatment history the patient's reported to have received.
Patient records # 2, 9, and 19 contained documentation indicating the patient's had received narcotic treatment services previously at other narcotic treatment programs. None of the three patient records reviewed contained documentation of any attempt to obtain the patient's prior treatment history from the previously attended narcotic treatment facilities. An interview with the facility director on January 11, 2011 at 1:15 p.m. confirmed that this was not being completed.
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Plan of Correction
715.9 Intake
Executive Director and Clinical Supervisor will develop a letter and release of Information to be sent to other NTP upon possible admission to ARS Lancaster. The form will be developed and staff will be trained on procedure by 3/15/2011. Audits are completed on 100 percent of admissions so compliance will be monitored an ongoing basis.
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715.10(a)(1) LICENSURE Pregnant patients
(a) A narcotic treatment program may place a pregnant patient, regardless of age, who has had a documented narcotic dependency in the past and who may return to narcotic dependency, on a comprehensive maintenance regime.
(1) For these patients, evidence of current physiological dependence on narcotic drugs is not needed if a narcotic treatment physician certifies the pregnancy and, exercising reasonable clinical judgment, finds treatment to be medically justified.
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Observations
Based on the review of patient records and discussion with facility staff, the facility failed to ensure the physician recorded in the patient's record the evidence of all findings and the criteria used to determine the reason for admitting and dosing a pregnant patient prior to the determination of current and one year history of narcotic dependency.
The findings include:
Twenty four patient records were reviewed January 10-12, 2011. One record was reviewed for the documentation of the physician's certification of the pregnancy and the finding that treatment was medically justified.
Patient # 13 was admitted on July 15, 2010. The physician failed to document the patient was pregnant in the patient record. There was no documentation of current dependency nor was there documentation of medical justification for the patient to be treated.
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Plan of Correction
715.10 Pregnant Patients
A review of regulation will be reviewed with Medical Director and his staff by 2/15/11. Medical Director and Executive Director will provide training on documentation of their findings to ensure that the medical staff is clearly documenting all components of regulation. Audits are completed on 100 percent of admissions so compliance will be monitored an ongoing basis.
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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 patient records, the facility failed to ensure that the patient was initially dosed following the completion of a drug-screen urinalysis in one of sixteen patient records.
The findings included:
Patient # 13 submitted an initial urine specimen for the purpose of urinalysis on July 15, 2010; the results were not received until July 16, 2010. The patient received her first dose of 20 mg of methadone on July 15, 2010.
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Plan of Correction
715.14 Urine testing
A review of regulation will be reviewed with Medical Director and his staff by 2/15/11. Medical Director and Executive Director will provide training on documentation skills to ensure that the treating physician has clearly documented rational for medicating a pregnant patient prior to receiving UDS results. Audits are completed on 100 percent of admissions so compliance will be monitored an ongoing basis.
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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
Based on the review of patient records and discussion with the facility director, the facility failed to ensure the physician dated the signature or signed the order within twenty-four hours after submitting a verbal order in four of four patient records reviewed.
The findings include:
Twenty-four patient records were reviewed January 10-12, 2011. Four records contained documentation of a physician's verbal orders. While the physician did sign these verbal orders, the physician either failed to date his signature or did not sign the verbal orders within twenty-four hours after submitting the verbal order. Therefore, in the records that the physician failed to date his signature there was no way to determine whether the verbal order was signed within twenty-four hours as required by regulation.
Patient record #1 contained documentation of verbal orders. A verbal order was documented on 9/10/2010; according to the physician schedule the doctor was not at the facility until 9/14/2010 to sign the verbal order within twenty-four hours. A verbal order was documented on 10/29/2010; according to the physician schedule the doctor was not at the facility until 11/2/2010 to sign the verbal order within twenty-four hours. A verbal order was documented on 11/12/2010; according to/the physician schedule the doctor was not at the facility until 11/16/2010 to sign the order within twenty-four hours. A verbal order was documented on 12/4/2010; the doctor did date his signature, however, it was not legible. A verbal order was documented on 12/12/2010; the doctor did not date the signature, therefore there was no way to determine if the verbal order was signed within twenty-four hours.
Patient record # 3 had a verbal order documented on 4/17/2010. The doctor did not sign the order within twenty-four hours; he verbal order was signed by the doctor on 4/19/2010.
Patient record # 12 had a verbal order documented on 1/2/10. The doctor did not date the signature, therefore there was no way to determine if the verbal order was signed within twenty-four hours.
Patient record # 24 had a verbal order documented on 9/21/10. The doctor did not date the signature, therefore there was no way to determine if the verbal order was signed within twenty-four hours.
An interview with the facility director confirmed that the physician failed to date his signature and that the dates were illegible, if written.
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Plan of Correction
715.17 Medication Control
A request for an exception was sent to Licensing. Until the determination is received, ARS Lancaster will begin to fax/scan a copy of the Verbal Order to the physician to ensure that the orders are signed within 24 hour period. Nursing will be trained on this process by 2/15/2011. In addition, a date stamp will be purchased by 2/15/2011. Twenty five (25) percent of charts will be audited monthly to ensure compliance for a period of 6 months.
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715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on the review of patient records the facility failed to send the required information to the receiving narcotic treatment program, as required in two of two records reviewed.
The findings include:
Twenty-four patient records were reviewed on January 10-12, 2011. Two patient records were reviewed for the required information to be sent to the transferred program. The facility failed to send the required information for patient records # 23 and 24.
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Plan of Correction
715.20 Patient Transfers
A new form will be developed with exact information that is to be sent to receiving facility. The information will be reviewed and Clinical Staff will be trained on required information to be sent to receiving facility by 2/28/2011. Compliance will be monitored on all transfers on an ongoing basis.
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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 review of patient records, the facility failed to ensure all efforts had been initiated to retain the patient prior to the involuntary termination in one of two records.
The findings include:
Twenty-four patient records were reviewed on January 10-12, 2011. Two patient records were involuntarily terminated from the program.
Patient # 14, was admitted on March 16, 2010 and involuntarily terminated on October 15, 2010 for financial reasons and missing counseling sessions. While financial responsibility was placed on the treatment plan, it was standardized and did not provide the specifics necessary to meet the goals. The facility did not document sufficient attempts to work with this patient in order to retain them in treatment.
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Plan of Correction
715.21 Patient Termination
Training will be provided to clinical staff on documentation of efforts to work with patients and how documentation should reflect treatment plan by 3/1/2011. All potential discharges will be reviewed by Executive Director, Clinical Supervisor and Medical Director prior to presentation to team to ensure that documentation reflects efforts to engage and work with patients. 100 percent of involuntary discharges will be monitored for compliance ongoing |
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 the review of patient records the facility failed to document an annual physical examination which included an annual reevaluation by the narcotic treatment physician in one of six records, as required. Additionally, two of the required annual physicals were late.
The findings include:
Twenty-four patient records were reviewed on January 10-12, 2011. Six patient records required an annual physical with a reevaluation by the narcotic treatment physician.
Patient record # 23 contained an annual physical that was completed by the Physician's Assistant. The physical failed to contain a statement of reevaluation by the narcotic treatment physician.
Patient record # 7 was admitted 4/24/2008. An annual physical was required to be completed by facility 4/24/2010. The annual physical was not completed until 6/25/2010, two months late.
Patient record # 12 was admitted on 7/31/2008. An annual physical was required to be completed by the facility by 7/31/2010. The annual physical was not completed until 11/15/2010, four months late.
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Plan of Correction
715.22 Patient Records
Annual physicals are completed on an annual basis. The record in question was a patient that was readmitted and the annual physicals were being completed based on the original admission date. The staff will be trained to complete annual physicals on most current date of admission. This will be addressed by Medical Director during individual supervision with Physician Assistant and Director of Nursing. Compliance will be monitored by auditing twenty five (25) percent of patient files for three months.
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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
Based on the review of patient records, the facility failed to complete all required laboratory tests as part of the admission process in four of seventeen patient records reviewed.
The findings include:
Twenty-four patient records were reviewed January 10-12, 2011. Seventeen patient records were reviewed for completed laboratory tests as part of the admission process, specifically a tuberculosis Mantoux test (PPD).
Patient records #10, 21, 22, and 24 did not have complete documentation of tuberculin Mantoux test having been administered as part of the admission process.
Patient record # 10 had a tuberculosis mantoux test planted on 9/16/2010. The results were not dated and there was no way to determine that the test was read within 48-72 hours. The results documented that the test was negative.
Patient record # 21 had a tuberculosis mantoux test planted on 10/19/2010. The facility failed to document the test results.
Patient record # 22 had a tuberculosis mantoux test planted on 8/12/2010. The facility failed to document the test results.
Patient record # 24 had a tuberculosis mantoux test planted on 8/26/2010. The results were not dated and there was no way to determine that the test was read within 48-72 hours. The results documented that the test was negative.
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Plan of Correction
715.23 Patient Records
The TB test was changed to reflect all of the data required when a patient is tested. Staff will be trained by Medical Director by 2/15/2011 on proper completion of the new form, including documenting the test that was read. Compliance will be monitored for a minimum of three months by auditing twenty five percent of patient records.
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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
Based on the review of patient records and an interview with the facility director and clinical supervisor, the facility failed to complete annual evaluations in accordance with the regulations in five of six patient records reviewed.
The findings included:
Twenty-four patient records were reviewed January 10-12, 2010. Six patient records required documentation of an annual clinical review. Four were late and one was not completed.
Patient # 4 was admitted on February 27, 2007. The annual review was due by February 27, 2010. The facility completed the annual review on December 20, 2010. It was ten months late.
Patient # 5 was admitted on October 13, 2008. The annual review was due by October 13, 2010. The facility completed the annual review on December 17, 2010. It was two months late.
Patient # 7 was admitted April 24, 2008. The annual review was due by April 24, 2010. As of the date of the inspection, the facility failed to document an annual review for this patient.
Patient # 12 was admitted on July 31, 2008. The annual review was due by July 31, 2010. The facility completed the annual review on September 8, 2010. It was over one month late.
Patient # 23 was admitted August 18, 2009. The annual review was due by August 18, 2010. The facility completed the annual review on December 3, 2010. It was over three months late.
The facility director and clinical supervisor confirmed that the annual reviews were late and missing in the one record.
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Plan of Correction
715.24 Patient Records
Clinical Supervisor has developed an excel spreadsheet and will train staff on utilization of tools in methasoft to ensure that annual reviews are completed per policy. An administrative day has been reinstituted on a monthly basis where audits will occur on active patient records to ensure compliance with this standard.
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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.
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Observations
Based on the review of patient records, the narcotic treatment program failed to document realistic short and long-term treatment goals in three of twelve patient records.
The findings include:
Twenty-four patient records were reviewed January 10-12, 2011. Treatment plans with realistic short and long-term treatment goals were reviewed in twelve patient records. The narcotic treatment program did not document short and long-term goals that were individualized for the patient in patient records #20, 21, and 22. These three records all documented a generic financial goal regardless if it was a problem for the patient.
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Plan of Correction
715.23 Patient Records
Training will be provided to clinical staff, by Clinical Supervisor ensuring that treatment plans are individualized and that every attempt to work with patients is documented clearly, reflecting the treatment plan goals. This training will occur by 2/28/2011
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