INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use a narcotic agent, specifically methadone, in the treatment of narcotic addiction. This inspection was conducted on September 20-22, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, JF Kennedy Community MH/MR Center 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 October 19, 2010.
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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, the facility failed to contact the previous facility for the patient's treatment history in two of two patient records reviewed.
The findings include:
Thirteen patient records were reviewed September 20-22, 2010. Two patients reported prior narcotic treatment history and required the facility contacting the prior treatment facility for the patient's treatment history. Patient records # 9 and 10 did not have documentation of any attempt to obtain the patient's prior treatment history from prior treatment facilities.
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Plan of Correction
Effective October 18, 2010 a patient's treatment history will be requested, with the patient's written consent, from the previous narcotic treatment program. The therapist completing the patient's psychosocial assessment/evaluation will be responsible for requesting this information. The Clinic Supervisor will be responsible for reviewing all new patients records at admission to ensure compliance. |
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 provide all the required information on consents to release information prior to the patient signing in four of four patient records.
The findings include:
Thirteen patient records were reviewed September 20-22, 2010. Four patient records were reviewed specifically for compliance with confidentiality. Three patient records, # 4, 10 and 11 had signed consents for a primary care physician without having identified who the primary care physician was. Patient # 12 had a signed consent for the patient's probation officer without specifying what information would be released.
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Plan of Correction
By November 2, 2010 staff will receive one training on the proper completion of consent to release information forms. Specifically, staff will be informed to include the exact name of the patient's primary care doctor. In addition, staff will be trained to consistently specify what information will be released to probation officers. The Clinic Director will be responsible for ensuring compliance by inspecting all consent forms at admission and at annual updates. |
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 the review of patient records and discussion with the facility director. The facility failed to randomize the monthly urinalysis for patients reviewed.
The findings include:
Thirteen patient records were reviewed September 20-22, 2010. Eight patient records were reviewed for randomized urine drug screens. While all eight contained urine drug screens that were obtained during a generally focused time of the month for the drug screens, five of the records were obtained during the same week of the month for the last four months reviewed.
Patient # 6 contained urine drug screens obtained during the first week of the past four months reviewed.
Patient # 7 contained urine drug screens obtained during the first week of the past four months reviewed.
Patient # 8 contained urine drug screens obtained during the second week of the past five months reviewed.
Patient # 9 contained urine drug screens obtained during the 10th and 19th day of the past four months.
Discussion with the facility director revealed that the facility does not complete urine drug screens after the third week of each month, or on the weekends. This procedure failed to provide randomized urine drugs screens as required.
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Plan of Correction
Effective October 1, 2010 we met with our nursing staff and revised our urine collection procedure to ensure randomization. The Clinic Supervisor will review this new procedure monthly to ensure compliance. |
715.20(3) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on the review of patient records, the facility failed to document what materials were sent to the receiving narcotic treatment program in one of one patient record.
The findings include:
Thirteen patient records were reviewed September 20-22, 2010. Two patient records were reviewed for documentation pertaining to the patient being transferred to another narcotic treatment program. Patient # 4 contained documentation the patient was transferred to another narcotic treatment program October 12, 2009. There was no documentation what materials were sent to the receiving facility. Patient record # 1 had documentation that the patient was transferred to another narcotic treatment program, but there was no other documentation to support this disposition.
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Plan of Correction
Effective November 9, 2010 staff will receive a training by the Division Director on the proper completion of all paperwork required to in patient transfers to another treatment facility. All of the pertinent documents will placed together in a single packet and filed in the record room cabinet for easy access and use. The Clinic Director will review all patient transfer documentation prior to submission to ensure compliance. |
715.20(4) 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.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on patient records, the facility failed to document notification to the transferring facility of the admission and the date of the initial dose of the patient in two of two patients.
The findings include:
Thirteen patient records were reviewed September 20-22, 2010. Two transfer patient records were reviewed.
Patient # 11 was transferred into the facility from another narcotic treatment facility on July 15, 2010. There was no consent for the referring facility or any documentation the facility had been notified.
Patient # 12 was transferred into the facility from another narcotic treatment program on May 13, 2010. There was no consent for the referring facility or any documentation the referring facility had been notified the facility of the admission and first dose of the patient.
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Plan of Correction
Effective November 9, 2010 All staff will be trained regarding the proper notification to transferring facility of the admission and the date of initial dose of the patient. The therapist completing the psychosocial assessment/evaluation will be primarily responsible for documenting notification to the transferring facility. Our Psychosocial assessment has been revised to capture this notification. The Clinic Director will review each transfer-in patient record at admisson for compliance. |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on the review of patient records, the facility failed to ensure the psychosocial evaluations were a clinical assessment of the historical data collected in three of three patient records.
The findings include:
Thirteen patient records were reviewed September 20-22, 2010. Three records were reviewed for psychosocial evaluations. Patient records # 10, 11 and 12 each had a psychosocial evaluation that was a repeat of patient statements and failed to evaluate the collected historical data.
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Plan of Correction
By November16, 2010 the Clinic Supervisor will conduct to staff trainings on proper evaluation of patient historical information. The Clinic Supervisor will also review patient evaluations at admission to ensure compliance. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on a review of patient records, the facility failed to document all of the required information in four of five patient records.
The findings include:
Thirteen patient records were reviewed September 20-22, 2010. Five patient records were reviewed for complete discharge summaries.
Patient records # 1, 3, 4 and 5 did not contain documentation of the reason the patient entered treatment.
Patient record # 5 did not document the patient's response to treatment following almost four years in treatment.
Patient records # 3, 4 and 5 did not include the patient's status or prognosis.
Patient # 2 was reported to have died, but there was no discharge summary completed. The last progress note was documented October 15, 2009.
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Plan of Correction
By November 16, 2010 the Clinic Supervisor will conduct two staff trainings on the proper documentation of all domains required for a patient discharge summary. Counselors will be taught that discharge summaries are 'stand alone' documents. The Clinic Supervisor will be responsible for reviewing all patient discharges to ensure compliance. |