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 October 7-8, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Dolminis 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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715.16(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.
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Observations
Based on the review of patient records, the facility failed to document that the narcotic treatment physician had determined whether a patient may be provided take-home medications in one of five patient records. The findings include:Sixteen patient records were reviewed on October 7-8, 2013. Five patient records were reviewed for take home medication information. There was no documentation in patient record # 2 that the narcotic treatment physician had determined whether the patient may be provided take-home medication.Patient # 2 was admitted on March 1, 2013. The record included a Request for Take Homes that was dated June 5, 2013. Under the nurses section, the nurse commented that the patient was unstable on his dose. Under the physician's section, the "deny" box was checked. There was no physician's name, physician's signature or a date of the denial. In addition, there was no documentation that the narcotic treatment physician determined whether the patient should or should not be provided take-home medications. The Facility Director was interviewed on October 8, 2013 and confirmed the findings.
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Plan of Correction
NT physician will sign all take-home request forms clearly identifying his decision of the request.
Counselor will ensure take home request form is completed in entirety, to include signature of the physician, prior to passing on to nursing team.
Nursing staff will ensure above compliance during random monthly medical chart audits.
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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 the review of patient records, the facility failed to document an annual reevaluation by the narcotic treatment physician in one of three patient records. The findings include:Sixteen patient records were reviewed on October 7-8, 2013. Three patient records required an annual reevaluation by the narcotic treatment physician. The facility failed to document an annual reevaluation by the narcotic treatment physician in patient record # 11.Patient # 11 was admitted on February 13, 2012. The annual reevaluation was completed on February 14, 2103 and was signed by the Certified Registered Nurse Practitioner. The annual reevaluation was not signed by the narcotic treatment physician. The Facility Director was interviewed on October 8, 2013 and confirmed the findings.
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Plan of Correction
NT physician will sign and/or counter sign all annual physical examination documentation.
Nursing staff will ensure all forms are appropriately signed during random monthly chart audits.
NT physician counter signed referenced annual exam document on 10.25.13.
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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 facility failed to document a treatment plan that outlined realistic short and long-term treatment goals in six of ten patient records. The findings include:Sixteen patient records were reviewed on October 7-8, 2013. Ten patient records required documentation of treatment plans that included realistic short and long-term treatment goals. The facility failed to document realistic short and long-term treatment goals on treatment plans contained in patient records # 5, 6, 7, 8, 9 and 13. Patient # 5 was admitted on June 25, 2013. The treatment plan, signed by the patient and staff on June 25, 2013, did not include documentation of short and long-term goals. Patient # 6 was admitted on July 9, 2013. The treatment plan, signed by the patient and staff on July 9, 2013, did not include documentation of short and long-term goals. Patient # 7 was admitted on April 6, 2013. The treatment plan, signed by the patient and staff on July 17, 2013, did not include documentation of short and long-term goals. Patient # 8 was admitted on May 7, 2013. The treatment plan, signed by the patient and staff on May 7, 2013, did not include documentation of short and long-term goals. Patient # 9 was admitted on June 18, 2013. The treatment plan, signed by the patient and staff on June 18, 2013, did not include documentation of short and long-term goals. Patient # 13 was admitted on January 29, 2013. The treatment plan, signed by the patient and staff on January 29, 2013, did not include documentation of short and long-term goals. The Facility Director was interviewed on October 8, 2013 and confirmed the findings.
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Plan of Correction
A new treatment plan form is currently being developed. Staff training and implementation will occur by 11/18/13.
The new format will clearly identify short/long term treatment goals mutually agreed upon as evidence by client and counselor signature.
Implementation of the new form will provide for correction of current deficient treatment plans.
Program director and clinical supervisor will monitor accuracy and timely completion when reviewing treatment plans during random monthly chart audits.
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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.
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Observations
Based on the review of patient records, the facility failed to document a treatment plan that identified the behavioral tasks a patient needed to perform in order to complete each short-term goal in six of ten patient records. The findings include:Sixteen patient records were reviewed on October 7-8, 2013. Ten patient records required documentation of treatment plans. The facility failed to document treatment plans that identified the behavioral tasks a patient needed to perform in order to complete each short-term goal in patient records # 5, 6, 7, 8, 9 and 13. Patient # 5 was admitted on June 25, 2013. The treatment plan, signed by the patient and staff on June 25, 2013, did not identify the behavioral tasks a patient needed to perform in order to complete each short-term goal. Patient # 6 was admitted on July 9, 2013. The treatment plan, signed by the patient and staff on July 9, 2013, did not identify the behavioral tasks a patient needed to perform in order to complete each short-term goal. Patient # 7 was admitted on April 6, 2013. The treatment plan, signed by the patient and staff on July 17, 2013, did not identify the behavioral tasks a patient needed to perform in order to complete each short-term goal. Patient # 8 was admitted on May 7, 2013. The treatment plan, signed by the patient and staff on May 7, 2013, did not identify the behavioral tasks a patient needed to perform in order to complete each short-term goal. Patient # 9 was admitted on June 18, 2013. The treatment plan, signed by the patient and staff on June 18, 2013, did not identify the behavioral tasks a patient needed to perform in order to complete each short-term goal. Patient #13 was admitted on January 29, 2013. The treatment plan, signed by the patient and staff on January 29, 2013, did not identify the behavioral tasks a patient needed to perform in order to complete each short-term goal. The Facility Director was interviewed on October 8, 2013 and confirmed the findings.
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Plan of Correction
A new treatment plan form is currently being developed. Staff training and implementation will occur by 11/18/13.
The new format will clearly identify short/long term treatment goals with listed objectives to achieve each.
Implementation of the new form will provide for correction of current deficient treatment plans.
Program director and clinical supervisor will monitor accuracy and timely completion when reviewing treatment plans during random monthly chart audits.
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