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 November 2-5, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health System 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 December 18, 2009.
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Plan of Correction
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715.9(b)(2) LICENSURE Intake
(b) Exceptions to the requirements in subsection (a) are:
(2) Upon readmitting a patient who has been out of a narcotic treatment program for 6 months or less after a voluntary termination, the narcotic treatment program shall update the information in and review the patient 's file to show current opiate narcotic dependency, but need not conduct a physical examination and applicable laboratory tests. Privileges earned during the previous treatment may be reinstated at the discretion of the narcotic treatment physician.
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Observations
Based on the review of patient records, the facility failed to update the patient records to show current opiate dependency in three of four patient records.
The findings include:
Fifty-eight patient records were reviewed on November 2-5, 2009. Of these records, three patient records required review for readmission documentation and updated information that provided current dependency.
Patient record # 49 was re-admitted and dosed on March 14, 2009 without medical documentation of current dependency. A urine drug screen test was conducted on March 16, 2009. The drug history was not updated since June 16, 2008.
Patient record # 50 was re-admitted July 27, 2009. The drug history was not updated medically since November 19, 2008, or clinically since December 13, 2007.
Patient record # 57 was re-admitted and dosed on September 17, 2009 without medical documentation of current dependency. A urine drug screen test was conducted on October 21, 2009. The drug history was not updated since February 28, 2009.
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Plan of Correction
Effective immediately, a client who has not been active in a methadone project for more than six months after voluntary termination shall be treated as a new admission and a new chart will be created. A client who has not been active in the methadone project for less than six months after a voluntary termination, will receive an evaluation interview and given priority consideration for re-admission. The physician will review the physical state of the client and will document previous and current opiate dependency. The facility physician will be responsible for updating the patient record to show current drug use status at the time of re-admission. In order to monitor this process is being followed, the Program Director will review the chart of each patient at the time of a re-admission. The procedure will continue to be followed each time a client is re-admitted to the facility. |
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 observation, the facility failed to maintain the confidentiality in accordance with 42 CFR 2.22 and 709.28.
The findings include:
On November 3, 2009 at approximately 4:30 PM, a counseling staff person was observed standing in the public lobby of the facility filling out patient-related forms for one patient while speaking with another patient. The Department staff stood directly next to the counselor during this exchange and was able to review all the documentation being filled out and also hear the conversation. The actions of the staff failed to provide confidentiality with regard to the conversation in a public place and the ability to observe and review patient information.
In addition, during the review of patient records on November 2-5, 2009, consent to release information forms in patient records # 3 and 4 did not identify the recipient of the information and that entity's or person's relationship to the patient in regards to the information being released.
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Plan of Correction
On November 2, 2009 a staff member was observed handling client information in an open area. The staff member was under contract from a Temporary Agency. The Agency and staff member were addressed and contract was terminated on November 6, 2009. Effective immediately, all staff members will complete all information on releases of information prior to client signing form. Twice a month, during team meeting, the Clinical Supervisors will instruct staff members on how to complete release of information forms properly. All documentation will be reviewed for completion by the clinical supervisors. If the documentation is incomplete, the clinical supervisor will notify the staff member. At anytime that the patient's confidentiality is not maintained, immediate disciplinary action will be taken by the clinical supervisors. |
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, the facility failed to ensure at least monthly random urine drug screens for six of thirty six patient records.
The findings include:
Fifty-eight patient records were reviewed November 2-5, 2009. Thirty-six patient records were reviewed for monthly urine drug screen results.
Patient record # 2 was missing a urine drug screen for September 2009.
Patient record # 3 was missing a urine drug screen for October 2009.
Patient record # 5 was missing a urine drug screen for September and October 2009.
Patient record # 8 was missing urine drug screens for October and November 2008, May, July, August 2009.
Patient record # 10 was missing urine drug screens for May, June, July and October 2009.
Patient record # 11 was missing a urine drug screen for October 2009.
The missing documentation was not made available during the on-site inspection.
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Plan of Correction
The Clinic Coordinator prints out a randomized list of clients for monthly urine drug screens using the AMS system. The Clinic Coordinator provides the list to the check-in clerk and nursing supervisor to schedule urine samples and collection for the day. The Nursing Staff and Supervisor will monitor this process for daily completion. The Clinic Coordinator together with the check in clerk will review all lists to guarantee all clients receive urine drug screenings monthly. The results of the toxicology screen will be filed in the patient's chart immediately after completion. |
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 the review of patient records, the facility failed to complete a review of the dosage levels at least twice a year for three of four patient records reviewed.
The findings include:
Fifty-eight patient records were reviewed November 2-5, 2009. Three patient records were reviewed for twice yearly dose reviews.
Patient # 1 was admitted 10-2-97. There were no dose reviews documented in the past 12 months reviewed.
Patient # 2 was admitted 12-2-05. There were no dose reviews documented in the past 12 months reviewed.
Patient # 5 was admitted 10-20-08. The last dose review was documented on 10-25-08.
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Plan of Correction
The Medical Director will review the dosage levels of all patients twice a year to determine the patient's therapeutic dosage at the time of review. The Medical Director will document review of dosage level in the AMS System. The Medical Director and nursing supervisor will complete quarterly reviews on random charts to monitor dosage levels and to make certain that reviews are being completed on a timely basis. |
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 7 of 24 patient records.
The findings include:
Fifty-eight patient records were reviewed November 2-5, 2009. Of these records twenty-four patient records were reviewed for psychotherapy hours during the first and second year of treatment. Eight patient records did not have an average of 2.5 hours per month as required.
Patient # 4, admitted 9-22-08, only received an average of 2 hours per month for the months of August, September and October 2009.
Patient record # 5, admitted 10-20-08, did not have any sessions documented after 9-28-09.
Patient record # 7, admitted 10-21-08, did not have any sessions documented after 8-21-09.
Patient record # 9, admitted 2-19-09, did not have any sessions documented between 5-21-09 and 8-26-09. There were no individual sessions documented since this patient was admitted, although one hour per month individual therapy was required.
Patient record # 42, admitted 10-6-09, did not have any sessions documented since admission.
Patient record # 47, admitted 7-31-09, did not have any sessions documented since admission.
Patient record # 51, admitted 7-23-09, did not have any sessions documented since admission.
Patient record # 55, admitted 10-2-09, did not have any sessions documented since admission.
During the inspection there was no explanation given for the missing documentation.
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Plan of Correction
During the client's first two years in treatment, the facility will provide clients with a minimum of 2.5 hours of psychotherapy services. The counselors will continously assess the client for additional services needed and will increase the hours of service accordingly.
On a weekly basis, the counselors will provide their clinical supervisors with weekly schedule for clients to be seen for groups and individual sessions. Furthermore, all counselors will provide the clinical supervisors with copies of their daily client's progress notes. The clinical supervisors will be able to compare daily client's progress notes with counselor's schedule. Client's not receiving services as needed, will be immediately contacted and scheduled.
During weekly supervision , the clinical supervisor will review the schedule with the counselor and monitor that all clients are being scheduled to receive services. The clinical supervisors will be repsonsible for monitoring the weekly schedule and following up with the counselors weekly.
During team meetings, clinical supervisors will provide in-service training on how to continously assess the client. The clinical supervisors will be respinsbile for conducting monthly chart reveiws to monitor services are being provided and to ascertain that all clients in treatment less than 2 years are receiving a minimum of 2.5 hours of psychotherapy per month. |
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 an average of 1 hour of psychotherapy per month during the patient's 3rd and 4th years of treatment in 2 of 3 patient records.
The findings include:
Fifty-eight patient records were reviewed November 2-5, 2009. Three patient records were reviewed for documentation of at least one hour of therapy during the 3rd and 4th year of treatment.
Patient record # 8 was admitted 8-2-05. There were no therapy sessions documented between 5-12-09 and 8-18-09.
Patient record # 17 was admitted 6-15-06. Patient was discharged as completed treatment 2-19-09. The last documented therapy session was 9-11-08.
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Plan of Correction
The facility clinical staff will provide clients in treatment during the third, fourth year, and thereafter, with a minimum of one hour of group or individual psychotherapy session per month. The clinical staff will provide ongoing assessment of the client to determine if additional services are needed. On a weekly basis the counselors will provide their clinical supervisors with a weekly schedule of clients to be seen for groups and individual sessions. At the end of each day, the counselors will provide the clinical supervisors with copies of daily client's progress notes. The clinical supervisors will be able to compare daily client's progress notes with counselor's schedule. Clients not receiving services as needed, will be immediately contacted and scheduled.
The clinical supervisors will provide in-service training during weekly team meetings on client assessments and provision of services.
Clinical supervisors will ensure that this process takes place by conducting chart reviews on a monthly basis. If the services are not being provided, detailed documentation will explain reasons for not providing services and will require an immediate action plan from the clinical staff and the supervisor. Supervisors will then follow-up with the clients and the counselors to make sure the client is receiving minimum services required. |
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 the review of administrative documentation, the facility failed to document a policy and procedure that was consistent with the standards regarding patient request for transfer.
The findings include:
Administrative documentation that included the policy and procedure manual was reviewed on November 2, 2009. The policy and procedures regarding patient requests for transfer stated that a patient would be transferred when "the methadone project determines that the transfer is in the best interest of the client's health or safety". Pennsylvania code requires that the patient's request to be transferred is acted on within 7 days of the patient's request.
This is a repeat citation; the facility was previously cited during the monitoring in September 2008.
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Plan of Correction
The facility failed to document a policy and procedure that was consistent with standards regarding patient request for transfer. Since this is a repeat citation, by 12/30/09, the Program Director will update the policy and procedure manual to address patient transfer. The policy will address the patient's request to transfer according to state standards 715.20. |
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 the review of patient records, the facility failed to document that it notified the referring facility of the admission and initial dosing of the patient in 4 of 4 patient records.
The findings include:
Fifty-eight patient records were reviewed November 2-5, 2009. Of these records four patient records were reviewed for documentation of notification to the referring facility of the admission and dosing of the referred patient. Patient records # 12, 37, 38 and 39 were each referred by another narcotic treatment program and there was no documentation of the referral source's notification of the admission and initial dosing of the patient.
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Plan of Correction
Effective immediately,the facility will follow the policy and protocol for patient transfers as follows. The clinic coordinator together with the behavioral medicine assessment department is responible for coordinating the transfer of clients to the facility. The clinical supervisors are responsible for reviewing documentation on all transferred clients. Once the client is accepted and the transfer is completed, the clinic coordinator is responsible for providing written documentation to the referring facility of the client's admission and initial dosing verification. On the admission date and upon completion of the transfer process, the clinic coordinator will provide written notification to the referring facility and will be filed in the client's chart immediately. Each time a transfer process is completed the clinical supervisors will review the client's record to ensure that this process is being followed.
The clinical supervisor will provide quarterly in-services to the staff on patient transfer process. |
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 reasons allowed by regulation in three of eight patient records reviewed.
The findings include:
Fifty-eight patient records were reviewed November 2-5, 2009. Of theses records, eight patient records were reviewed for involuntary, administrative or therapeutic, discharge. Three patient records contained documentation of the patient being discharged for reasons other than those listed by regulation.
Patient # 18 was terminated for un-excused absences on 9-18-09. The only documentation of intervention was one probation contract on 6-30-09.
Patient # 19 was terminated on 5-6-09 for not meeting financial obligations. There was only one documented intervention of a behavioral contract on 10-23-08.
Patient # 24 was terminated on 2-4-09 for not having insurance, though the box checked on the discharge summary stated the patient left against facility advice. The actual documentation stated she left because she did not have insurance.
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Plan of Correction
On December 7, 2009, Program Director and Clinical Supervisors reviewed the policies and procedures protocol on patient termination will all staff members. All counselors received a copy of the policy and procedures on patient termination. Counselors were again made aware of restrictions for involuntary terminations. Effective immediately counselors will not initiate any client termination process without the approval of the clinical supervisor. The supervisors will discuss with the counselor reasons for discharge and will review the client's chart for written documentation leading to the discharge. The clinical supervisors will then consult with the program director with the reason for involuntary termination and a decision will be made.
During weekly team meetings, the clinical supervisors will provide in-service training to staff on criteria for client involuntary termination.
The clinical supervisors will be responsible for reviewing all discharges to ensure this process is being followed. The clinical supervisor will forward all discharged records to program director who will monitor and assure that clinical staff and supervisors are adhering to restrictions for involuntary termination.
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715..23(b)(1) LICENSURE Patient records
(b) Each patient file shall include the following information:
(1) A complete personal history.
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Observations
Based on the review of patient records and review of administrative documentation, the facility failed to document a complete personal history according to the facility policy and procedure manual in thirteen of eighteen patient records.
The findings include:
Fifty-eight patient records were reviewed November 2-5, 2009. Eighteen patient records were reviewed for complete personal history documentation.
The policy and procedure manual was reviewed on November 2, 2009 for the facility's time frame for completing the personal history. The facility policy and procedure manual stated the personal history was to be completed within 30 days of the patient's admission.
Patient record # 40 was admitted 5-21-09. The history was to be completed by 6-20-09. It was completed 6-24-09 without documentation citing why it was late.
Patient record # 41 was admitted 5-19-09. The history was to be completed by 6-18-09. It was completed 6-26-09 without documentation citing why it was late.
Patient record # 43 was admitted 8-24-09. The history was to be completed by 9-23-09. It was completed 9-30-09 without documentation citing why it was late.
Patient record # 45 was admitted 6-1-09. The history was to be completed by 7-1-09. It was not completed at the time of the review.
Patient record # 46 was admitted 7-2-09. The history was to be completed by 8-1-09. It was completed 9-10-09 without documentation citing why it was late.
Patient record # 49 was admitted 3-14-09. The history was to be completed by 4-13-09. It was not completed, but instead a history from a previous admission dated 6-15-07 was used.
Patient record # 50 was admitted 7-27-09. The history was to be completed by 8-26-09. It was not completed, but instead a history from a previous admission dated 12-13-07 was used.
Patient record # 51 was admitted 7-23-09. The history was to be completed by 8-22-09. It was not completed at the time of the review.
Patient record # 53 was admitted 7-31-09. The history was to be completed by 8-30-09. It was not completed at the time of the review.
Patient record # 54 was admitted 8-27-09. The history was to be completed by 9-26-09. It was not completed at the time of the review.
Patient record # 55 was admitted 10-2-09. The history was to be completed by 11-1-09. It was not completed at the time of the review, November2 -5, 2009.
Patient record # 57 was admitted 9-17-09. The history was to be completed by 10-17-09. It was not completed, but instead a history from a previous admission dated 2-28-08 was used.
Patient record # 58 was admitted 7-2-09. The history was to be completed by 8-1-09. It was not completed, but instead a history from a previous admission dated 8-8-00 was used.
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Plan of Correction
On December 7, 2009 during a staff meeting, staff members were addressed on the Goldman Clinic policy and procedure for completing psychosocial history within 30 days of the patient's admission. Effective immediately, staff members will complete all psychosocial histories within 30 days from client admission. The Clinical Supervisors are responsible for reviewing new admission's charts. There will be monthly chart reviews by the Clinical Supervisors to monitor that this process is being followed. |
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 complete annual physicals or a re-evaluation by the physician in eight of eight patient records reviewed.
The findings include:
Fifty-eight patient records were reviewed November 2-5, 2009. Eight patient records were reviewed for annual physical exams.
Patient # 1 was admitted 10-2-97. The last annual physical exam was dated 10-16-07.
Patient # 4 was admitted 9-22-08. There was no annual physical exam documented in the patient record during review.
Patient # 5 was admitted 10-20-08. There was no documented physical exam in the patient record during the review.
Patient # 6 was admitted 10-12-07. There was no documented physical exam in the patient record during the review.
Patient # 7 was admitted 10-21-08. The annual physical exam was completed on 10-6-09 by the Certified Physician Assistant (PAc), but did not include a re-evaluation by the physician.
Patient # 8 was admitted 8-2-05. The annual physical exam was completed on 8-14-09 by the Certified Physician Assistant (PAc), but did not include a re-evaluation by the physician.
Patient # 10 was admitted 10-11-04. The last annual physical exam was dated 10-16-07.
Patient # 11 was admitted 1-28-08. The annual physical exam was completed on 1-30-09 by the Certified Physician Assistant (PAc), but did not include a re-evaluation by the physician.
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Plan of Correction
At the beginnning of each month, the nursing staff together with the physician assistant will compile a list of clients due for annual physicals and re-evaluations. A message will be placed in the AMS system as a reminder to the client and the staff of the physical due date. The Medical Director will then receive the completed physical for review.Once the physical exam is received, the clinic coordinator will immediately file the form in the client's record. The medical director will monitor this process to assure all annual physicals and re-evaluations are being completed and filed in the client's record promptly.
While reviewing records, the medical records supervisor together with the clinical supervisors will assure that all annual physical exams and re-evaluations are comppleted and filed in the client's record. In addition, during monthly chart reviews and weekly clinical supervisions, the clinical supervisor will review client's charts and will immediately notify the medical director of any charts missing annual physical exams or re-evaluations. |
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 nine of eighteen patient records reviewed.
The findings include:
Fifty-eight patient records were reviewed November 2-5, 2009. Eighteen patient records were reviewed for completed laboratory tests as part of the admission process, specifically a tuberculosis Mantoux test (PPD). Facility policy required a PPD test to be completed at admission.
Patient # 42 was admitted 10-6-09. There was no documentation of a PPD or chest x-ray being completed as part of the admission process.
Patient # 44 was admitted 10-22-09. There was no documentation of a PPD or chest x-ray being completed as part of the admission process.
Patient # 45 was admitted 6-1-09. There was no documentation of a PPD or chest x-ray being completed as part of the admission process.
Patient # 49 was admitted 3-14-09. There was no documentation of a PPD or chest x-ray being completed as part of the admission process.
Patient # 50 was admitted 7-27-09. There was no documentation of a PPD or chest x-ray being completed as part of the admission process.
Patient # 52 was admitted 7-8-09. There was no documentation of a PPD or chest x-ray being completed as part of the admission process.
Patient # 55 was admitted 10-2-09. There was no documentation of a PPD or chest x-ray being completed as part of the admission process.
Patient # 57 was admitted 9-17-09. There was no documentation of a PPD or chest x-ray being completed as part of the admission process.
Patient # 58 was admitted 7-2-09. There was no documentation of a PPD or chest x-ray being completed as part of the admission process.
This is a repeat citation.
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Plan of Correction
Effective immediately, the nursing staff will administer a mantoux test to all new admissions prior to the client receiving the first methadone dose. Using the AMS system the nursing staff will communicate with the client to follow up and document results of test.
The nursing staff together with the physician assistant will continue to administer a mantoux test to all clients annually. The nursing staff and the physician assistant will compile a monthly list of clients due for testing. A message will placed in the AMS System as a reminder to the client and the staff of the mantoux test due. The medical director wil supervise and monitor nursing staff/phyician assistant to ensure all mantoux test are being administered to the clients. During the month of December 2009, this process was communictated to all nursing staff and the process is effective to begin immediately. A quarterly review of this process will be done to monitor effectiveness. The medical director will provide ongoing training and supervision to promote compliance of this process. |
715.23(b)(11) LICENSURE Patient records
(b) Each patient file shall include the following information:
(11) Counselor notes regarding patient progress and status.
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Observations
Based on review of patient records, the facility failed to provide the required information regarding the patient's progress and status in the clinical notes in 16 of 28 patient records reviewed.
The findings include:
Fifty-eight patient records were reviewed November 2-5, 2009. Twenty eight patient records were reviewed for counselor notes regarding patient's status in treatment. Sixteen patient records did not provide current information on the patient's treatment status as required.
The last documentation regarding patient's progress for patient # 3 was September 23, 2009.
The last documentation regarding patient's progress for patient # 5 was September 28, 2009.
The last documentation regarding patient's progress for patient # 7 was August 21, 2009.
The last documentation regarding patient's progress for patient # 14 was December 23, 2008. Patient was discharged 2-25-09.
The last documentation regarding patient's progress for patient # 17 was September 11-08. Patient was discharged as treatment complete on 2-19-09.
The last documentation regarding patient's progress for patients # 40 and # 41 was October 6, 2009.
The last documentation regarding patient's progress for patient # 43 was October 15, 2009.
The last documentation regarding patient's progress for patient # 51 was August 11, 2009.
The last documentation regarding patient's progress for patient # 56 was October 16, 2009.
The last documentation regarding patient's progress for patient # 58 was October 16, 2009.
There were no progress notes of patient's status documented for patients # 42, 44, 47 and 55.
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Plan of Correction
During staff meeting on January 11, 2010,the program director communicated to all clinical staff the protocol for maintaining client's record documentation; client progress and status.
The clinical staff will complete a progress note every time they meet with a client for individual or group therapy. The note will clearly detail the client's progress and status. Furthermore, any appointment cancellation or NO show is to be documented in the client's record with next appointment scheduled. The client record is to be up to date at all times. At the end of each day, the counselors need to provide their clinical supervisor with daily progress notes. Supervisors are responsible for reviewing the progress notes and providing feedback to the counselors accordingly. By February 1, 2010 and thereafter, all counselors will be trained on client record documentation. During weekly supervision and monthly chart reviews, the clinical supervisors will review client's records to monitor clinical staff are documenting patient progress and status on progress notes. |
715.23(b)(14) LICENSURE Patient records
(b) Each patient file shall include the following information:
(14) Case consultation notes regarding the patient.
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Observations
Based on the review of patient records, the facility failed to complete case consultations as required in 15 of 19 patient records reviewed.
The findings include:
Fifty-eight patient records were reviewed November 2-5, 2009. Nineteen patient records were reviewed for case consultations.
Patient # 1 did not have a case consultation documented since 4-2-07.
Patient # 4 did not have documentation of the annual case consultation due by 9-22-09.
Patient # 5 did not have documentation of the annual case consultation due by 10-20-09.
Patient # 6 did not have documentation of the annual case consultation due by 10-12-09.
Patient # 7 did not have documentation of the annual case consultation due by 10-21-09
Patient # 8 did not have documentation of the annual case consultation due by 8-2-09
Patient # 49 did not have documentation of have a case consultation due by 10-6-09.
Patient record # 10 contained documentation by the clinical supervisor that the case consultation was not done.
Patients # 45, 46, 47 50, 52, 53 and 58 had no documented case consultations in the record during the review.
Patient record # 1, 11, 15, 17, 18, 19 and 24 did not have any staff listed as participating in the consultation, but was written as a progress note of a session with the patient.
Patient records # 2, 5, 6, 7, 12 and 21 did not have the required case consultations at least quarterly.
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Plan of Correction
By January 30, 2010, all clinical staff will receive in-service training on how to complete case consultations as scheduled. Clinical Supervisors will continue to provide in-service training to the clinical staff on a quarterly basis to promote compliance of this process.
By 2/1/10, all clinical staff will be completing case consultations as scheduled and documentation will be filed in the client's record.
The clinical supervisors will perform monthly chart reviews to monitor the completion of all case consultations. Any client record missing a case consultation at the time of the review will be immediately forwarded to the clinical staff for completion. |
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 document an aftercare plan in 4 of 4 patient records that required one.
The findings include:
Fifty-eight patient records were reviewed November 2-5, 2009. Four patient records required an aftercare plan or documentation that the patient refused.
Patient records # 17, 29, 31 and 36 were all discharged as treatment completed. There was no documentation in the patient records of an aftercare plan being either developed, offered or refused.
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Plan of Correction
During staff meeting on December 7, 2009, counselors were addressed on protocol for aftercare plans completion. Clinical Supervisors will continue to address this protocol during monthly team meetings. The aftercare plan will be completed and signed by all clients completing treatment sucessfully. If the client refuses to participate in any aftercare, the counselor will document refusal of aftercare plan in the discharge summary. Clinical Supervisors will monitor this process is being followed by reviewing and signing the discharge summary. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on the review of patient records, the facility failed to document the attempt or completion of patient follow up contact in 7 of 20 patient records reviewed. .
The findings include:
Fifty-eight patient records were reviewed November 2-5, 2009. Twenty patient records were reviewed for follow-up documentation.
Patient records # 13, 14, 23, 24, 32, 33 and 36 did not have documentation of patient follow up or an attempt to contact.
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Plan of Correction
Effective immediately, the clinical coordinator will monitor follow up on all discharged clients. The clinic coordinator will complete follow up after a discharge occurs according to the policy. Once the follow up is completed the clinical coordinator will initial and date the follow up form in the client's discharged record.
On or around 1/30/10, the clinical coordinator will receive training on how to complete discharged clients follow up on a consistent basis.
Effective immediately, increased supervision will be provided by the Program Director who will monitor this process is being followed. On a monthly basis the program director will review five discharged records to review if follow up is being completed as stated.
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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 review of patient records, the facility failed to ensure that all annual evaluations were completed as required in three of nine patient records.
The findings include:
Fifty-eight patient records were reviewed November 2-5, 2009. Nine patient records were reviewed for annual evaluations.
Patients # 1 and 10 had their last annual evaluation completed in October 2007.
Patient # 2 had an annual evaluation with the future date of December 2, 2009, it was due 1-15-09.
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Plan of Correction
Annual evaluations will be completed by clinical staff on the client's anniversary date. Once the annual evaluaton is completed and signed by all staff members, it will be filed in the client's record.
Clinical Supervisors will provide ongoing in-service trainings to clinical staff on patient records and completion of annual evaluations.
Effective immediately, increased clinical supervision will be provided by all supervisors responsible for monitoring client's records. During weekly supervision and monthly chart reveiws, clinical supervisors will ensure that client's records are up to date. Any client record missing an annual evaluation , at the time of review, will be immediately forwarded to the clinical staff for completion. |
715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
Based on the review of administrative documentation, the facility failed to provide complete policy and procedures addressing unusual incidents.
The findings include:
Administrative documentation that included the policy and procedure manual for the facility was reviewed on November 4, 2009. The policy addressing unusual incidents failed to include procedures to respond to the unusual incidents that were listed in the policy.
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Plan of Correction
By January 10, 2010, the Program Director will review and revise the present policy and procedure on unusual incidents. The revised policy will be approved by the Department of Performance Improvement and the vice president of behavioral medicine.
On or around 1/29/2010, the program director will provide in-sevice training to all clinical supervisors and staff members on the revised policy on addressing unusual incidents. All clinical supervisors and staff members will receive a copy of the updated policy on addressing unusual incidents at the facility. The program director and clinical supervisors will be responsible for assuring this protocol is being followed accordingly. |
709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
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Observations
Based on observation, the facility failed to provide the requested records in a manner consistent within available time frames, during three of the four days of monitoring.
The findings include:
On November 2, 2009 at about 11:00 AM, the facility was presented with a request to provide the reviewers with patient records obtained from two lists of patient records. The list included one for current patients and the second list was for three pregnant patients. The records did not start to arrive until approximately 12:00 PM. It took until 3:00 PM to have most of the records. All but one of the pregnant patient records was delivered by 3:00 PM. The third pregnant patient record was not delivered for review until November 3, 2009 at approximately 9:45 AM.
On November 3, 2009 at about 11:45 AM, another request for patient records from another patient list was presented to the director and it was specifically requested that the records be provided to the reviewers more quickly than the previous day.
On November 4, 2009 at about 8:45 AM, another list of patient records to be reviewed was presented to the director. At approximately 10:00 AM, the Quality Assessment (QA)officer came to the office and learned of the delay in receiving the requested records. The QA officer spoke with the director regarding the timely acquisition of the requested charts, but it still took several hours to obtain all of the requested patient records.
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Plan of Correction
On December 7, 2009, the facility began to address the staff access to records. Effective immediately, all client's records to be returned to the file room soon after completing the session with the client or by the end of the each day.
During the month of December 2009, the program director completed an unannounced mock inspection requesting ten client's records at random. The program director will continue to monitor time frame for receiving charts.
Furthermore, the facility began to re-organize the discharge file room. This re-organization will facilitate timely retrieval of records.
During weekly supervision, all supervisors will remind clinical staff to return client's records to the file room on a daily basis.
Clinical supervisors and program director will be responsible for assuring that all clinical staff adheres to this process. |