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 28, 2011 through December 1, 2011 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.
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Plan of Correction
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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of patient records, the facility failed to have a narcotic treatment physician make a face-to face determination of dependence and document in the patient's record the basis for determining an individual's physiological dependence upon a narcotic drug prior to the administration of a narcotic medication in one patient record.
Findings:
Forty-five patient records were reviewed November 29, 2011 through December 1, 2011. In patient record #6, there was no documentation verifying that the narcotic treatment physician made a face-to-face determination of the patient's physiological dependence upon a narcotic drug prior to administration of the narcotic medication.
Patient # 6 was admitted July 11, 2011. The patient received their first dose of methadone of 5 mg on July 18, 2011 while the patient was in the residential program of the project. The documentation that was reviewed in the patient record showed that the face-to-face determination and the one year opiate addiction was documented on July 21, 2011, three days following the initial dose of methadone.
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Plan of Correction
Patients seeking admissions for medication assisted treatment will meet with the clinic's physician.
The clinic's physician is responsible for determining that the patients eligible for admission. The physician will verify and document current dependency.
By January 30, 2012, the education department will provide staff with a training on Intake and Screening process for admission. The director will be reviewing 3 admission records per month to monitor this process is being followed. |
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 narcotic treatment facility for the patient's treatment history in two of three patient records reviewed.
The findings include:
Forty-five patient records were reviewed November 29, 2011 through December 1, 2011. Three patient records required contacting the prior narcotic treatment facility for the previous treatment history.
Patient records # 10 and 12 contained documentation the patient's had previously received narcotic treatment services. Patient records # 10 and 12 failed to contain documentation of any attempt to obtain the patient's prior treatment history from the previously attended narcotic treatment facilities.
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Plan of Correction
Effective immediately, the facility will contact the previours narcotic treatment program to request the patient's treatment history. The clinic coordinator will be responsible for getting the patient's written consent and following up in getting the documentation. The clinic coordinator will document in the chart attempts to gather information.
By 1/15/12, the clinic coordinator will participate in a training on Intake process. The program director will review new admissions charts at random to monitor this process is being followed. |
715.13(a) LICENSURE Patient identification
(a) A narcotic treatment program shall use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
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Observations
Based on review of the facility's policy and procedures, the facility's computer program and patient record documentation, the facility failed to have all patient pictures in the system to identify the patient prior to administration of a narcotic agent.
The findings include:
The facility's policy and procedures were reviewed on November 28, 2011. According to the facility 's policy, " Each client must obtain his/her ID card from the clerk at the check-in desk before entering the dispensing line. The clerk checks the digitized picture of the client against the actual client. Once positive identification is verified, the client is permitted to enter the dosing line, five at a time....... To dispense methadone, the nurse confirms the authenticity of the client against the picture which opened on the computer screen."
While observing patient dosing on November 29, 2011, it was observed that not all patient's had a photo in the facility's computer system. There was no way for the clerk or the nurse to verify the patient's ID against the computer system. Forty-five patient records were reviewed on November 29, 2011 through December 1, 2011. Twenty-one patient records were reviewed specifically for their photo identification in the facility's computer system. The facility failed to have digitized photos in 16 of 21 records reviewed, specifically patient records # 5, 6, 7, 9, 11, 12, 13, 14, 15, 17, 18, 19, 20, 22, 23, and 24.
During staff interviews it was revealed that the computer system was installed in August 2011. Staff confirmed that not all patient photos have been entered in the system.
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Plan of Correction
The facility has purchased and installed a new patient information system called AVATAR.
By 1/30/12, the clinical coordinator will have all patient pictures in the system allowing the nursing staff to identify the patient prior to medication. In the meantime patients with no picture in system will show their PA Pennsylvania State ID to the nurses prior to being medicated.
The program director will supervise the process to assure that all identifying pictures are in the system by 1/30/12. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on a review of administrative documentation during the inspection of the dispensing area, the facility failed to ensure the photo identification maintained onsite was updated every two years as required, per the facility's policy in three of five identification cards reviewed.
The findings include:
The facility's policy was reviewed on November 28, 2011. According to the facility's policy. an ID card is issued to each patient in plastic. The facility's policy stated that the termination of the ID card is two years from issuance date. An inspection of the dispensing area was conducted on November 29, 2011 between 9:10 AM and 9:50 AM. Patients were observed as they handed their respective photo ID cards to the dispensing nurse prior to being dosed with a narcotic agent. The dispensing nurse placed the photo ID card into a stack prior to placing them in a card box. Five ID's were reviewed and three ID's had expired, specifically patient 's # 1, 2, and 3.
Patient # 1's ID had expired 1/11/2009.
Patient # 2's ID had expired 2/1/2008.
Patient # 3's ID had expired 8/27/2010.
The two nurses on duty confirmed that the ID cards had expired.
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Plan of Correction
The facility's policy will be revised to read the patient photograph identification card will be updated every 3 years.
The clinic coordinator and the check-in clerk will review all photo identification cards. All expired cards will be updated by 1/15/12. The program director will provide staff with an in-service on the revised policy and procedure for patient identification cards. The clinic coordinator and check-in clerk will review cards on a monthly basis to assure ongoing compliance. |
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 that a random urine drug screen was completed monthly for 14 of 30 patient records.
The findings include:
Forty-five patient records were reviewed November 29, 2011 through December 1, 2011. Thirty patient records were reviewed for monthly urine drug screen results. The facility failed to document monthly results in patient records # 4, 7, 8, 10, 12, 15, 18, 19, 21, 23, 25, 26, 28 and 34.
Patient record # 4 was missing a urine drug screens for August 2011 and October 2011.
Patient record # 7 was missing a urine drug screen for September 2011.
Patient record # 8 was missing a urine drug screen for October 2011.
Patient record # 10 was missing a urine drug screen for October 2011.
Patient record # 12 was missing a urine drug screen for October 2011.
Patient record # 15 was missing a urine drug screen for August 2011.
Patient record # 18 was missing a urine drug screen for September 2011.
Patient record # 19 was missing a urine drug screens for May 2011 and September 2011.
Patient record # 21 was missing a urine drug screen for September 2011.
Patient record # 23 was missing a urine drug screen for December 2010 and January 2011.
Patient record # 25 was missing a urine drug screen for October 2011.
Patient record # 26 was missing a urine drug screen for August 2011.
Patient record # 28 was missing a urine drug screen for August 2011 and October 2011.
Patient record # 34 was missing a urine drug screen for October 2011.
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Plan of Correction
The facility will complete monthly drug screening for all patients. The check-in clerk will be responsible for printing a list from the client information system AVATAR. The nursing staff will schedule and collect all samples for the day. The nursing staff and check-in clerk will review the list daily to assure all patients are being tested monthly. The test results will be reviewed and signed by the medical director before filing results in the patient's chart.
By 1/20/12, the Program Director will meet with staff to address new protocol for urine testing. |
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 the review of patient records, the facility failed to ensure the physician documented in the patient record the rationale for granting take home medication in three of ten patient records.
The findings include:
Forty-five patient records were reviewed on November 29, 2011 through December 1, 2011. Ten patient records were reviewed for take home medication documentation. Per regulation, the narcotic treatment physician shall document in the patient record the rationale for permitting take home medication. Patient records # 25, 26, and 29 did not have the physician's rationale for granting the take home medication.
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Plan of Correction
Effective immediately, the clinic's physician will review all documentation presented to assure that the patient meets the criteria for take home privilege. If documentation is approved, the physician is then responsible for documenting in the patient record the rationale for approving take home medication. On a monthly basis, the medical record supervisor will review random charts to assure this process is being followed.
Beginning January 15, 2012 and ending March 30, 2012, all staff will receive a series of 3 trainings on documentation of take home privileges. |
715.16(f) LICENSURE Take-home priveleges
(f) An exception granted under subsection (d) shall continue only for as long as the temporary disability or exceptional circumstance exists. When a patient is permanently disabled, that case shall be reviewed at least annually to determine whether the need for the exception still exists.
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Observations
Based on the review of patient records, the facility failed to ensure that when a patient received take home privileges by exception for a permanent disability, the case shall be reviewed at least annually to determine whether the need for the exception still exists in three of three records reviewed.
The findings include:
Forty-five patient records were reviewed November 29, 2011 through December 1, 2011. The records reviewed included three patients who received six day takehomes granted by medical exception. The facility failed to document annually that the exception still existed and were required in patient records # 15, 44, and 45.
Patient # 15 was admitted December 1, 1994. A review of the patient's record revealed that the patient received six day take homes by medical exception. The last documented review of the medical exception was on November 27, 2009. The facility failed to document annually that the need for the exception still existed.
Patient # 44 was admitted March 6, 2002. A review of the patient's record revealed that the patient received six day take homes by medical exception. The last documented review of the medical exception was January 27, 2009. The facility failed to document annually that the need for the exception still existed.
Patient # 45 was admitted October 2, 1997. A review of the patient's record revealed that the patient received six day take homes by medical exception. The last documented review of the medical exception was February 12, 2007. The facility failed to document annually that he need for the exception still existed.
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Plan of Correction
The program director and medical director will review all records of patients presently on reduced schedule by exception for a permanent disability. Patients no longer eligible for take home privileges will be restored to a 7 day schedule.
On an amnnual basis, all records of patients with reduced schedule by exception will be reviewed by the Medical Director and Program Director. Updated medical documentation must be provided and filed in record sustaining that the dissability continues to exist.
By 1/20/12, the medical director will provide clinical staff with training on criteria for take home privilege by exception. The clinical supervisors and program director will review the records for patients with take homes by exceptions to ensure the patient is still eligible for a take home schedule. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on the review of patient records, the facility failed to ensure the physician completed a written dosage change in five of five patient records reviewed.
The findings include:
Forty-five patient records were reviewed November 29, 2011 through December 1, 2011. Five patient records reviewed required documentation of the patient's induction into methadone maintenance. Patient #'s 5, 10, 21, 27 and 40 had documentation of standard induction orders. The facility failed to ensure that the physician assessed each patient prior to determining the dose increase.
Patient # 5 was admitted July 22, 2011. The physician wrote a standing order for the initial dose of 30 mgs to be administered on 7/22/2011, 40 mgs to be administered on 7/23/2011, 50 mgs to be administered on 7/24/2011, stop and reevaluated, adjust PRN.
Patient # 10 was admitted August 15, 2011. The physician wrote a standing order for the initial dose of 30 mgs to be administered on 8/15/2011, 40 mgs to be administered on 8/16/2011, 50 mgs to be administered on 8/17/2011, 60 mgs to be administered on 8/17/2011.
Patient # 21 was admitted March 11, 2011. The physician wrote a standing order for the initial dose of 30 mgs to be administered on 3/11/2011, 35 mgs to be administered on 3/12/2011, 40 mgs to be administered on 3/13/2011, 45 mgs to be administered on 3/14/2011 and 50 mgs to be administered on 3/15/2011.
Patient # 27 was admitted June 28, 2011. The physician wrote a standing order for the initial dose of 30 mgs to be administered on 6/28/2011 and increase 10 mgs a day until the patient reaches 50 mgs.
Patient # 40 was admitted on February 15, 2011. The physician wrote a standing order for the initial dose of 30 mgs to be administered on 2/15/2011, 40 mgs to be administered on 2/16/2011, 50 mgs to be administered on 2/17/2011, 60 mgs to be administered on 2/18/2011 and 70 mgs to be administered on 2/19/2011.
This issue of standing orders was addressed September 4, 2007 when the DEPARTMENT OF HEALTH & HUMAN SERVICES Substance Abuse and Mental Health Services Administration addressed all narcotic treatment facilities, stating in part the following:
"In determining the initial dose for each individual patient, the
physician should consider factors such as body weight, size, other substance use and
abuse, diet, co-occurring disorders (check for prescribed SSRIs, benzodiazepines, HIV
medications, anti-seizure medication, etc.) and medical diseases, genetic factors, and
tolerance. The drug labeling states that "methadone's pharmacokinetic properties,
coupled with high inter-patient variability in its absorption, metabolism, and relative
analgesic potency, necessitate a cautious and highly individualized approach to
prescribing." Even though the Treatment Improvement Protocol (TIP #43) and drug
labeling state that a typical first dose of methadone for a patient actively abusing opioids
is 20 to 30 milligrams, some patients may require a much lower dose. According to 42
CFR 8.12 (h) (3) (ii), "...the initial dose of methadone shall not exceed 30 milligrams
and the total dose for the first day shall not exceed 40 milligrams.. .." (emphasis added).
The initial methadone dose should be appropriate for the individual patient, with the
maximum initial dose being 30 mg. Clearly, a 30-mg dose should not be the initial dose
for all patients.
Of note, there has been a rapid increase in the abuse of the opioid-type pain relieving
medications. Typically, hydrocodone and oxycodone are the drugs of choice, and the
resulting addiction is treated by the OTPs. These are short-acting opioids with a half-life
of 2 to 4 hours. However, methadone has an elimination half-life that can vary from 8 to
59 hours depending on the individual being treated. Thus, methadone induction must be
approached cautiously.
Because methadone overdose deaths have occurred in early treatment due to the drug's
cumulative effects of the first several days, it is also important to be cautious when
adjusting the dose. According to the drug labeling, the peak respiratory depressant
effects of methadone typically occur later and persist longer than its peak analgesic effects, which can contribute to cases of iatrogenic overdose, particularly during
treatment initiation and dose titration. With repeated dosing, "methadone may be
retained in the liver and released slowly, prolonging the duration of action despite low
plasma concentrations." The drug labeling also states that "steady-state concentrations
are not usually attained until 3 to 5 days of dosing," and that doses "will 'hold' for a
longer period of time as tissue stores of methadone accumulate." Therefore, patients
should be closely monitored during the induction phase, and the increase in dose should
be under the close supervision of a physician as stated in 42 CFR 8.12 (h)(4), 'Dosing
and administration decisions shall be made by a program physician familiar with the most
up-to-date product labeling' ."
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Plan of Correction
The initial dose of methadone will be ordered by the program physician at the time of admission.
Effective immediately, patient will be assessed prior to determinig a dose increase if needed. Increase will be based on patient's symptoms associated with abstinence. Assessment of the patient's overall condition with special attention to his/her mental status.
Subsequent methadone increases during induction will be via verbal orders from the program physicians.
Verbal orders will be noted and signed by those dispensing methadone.
Verbal orders will subsequently be signed and dated by the program physician.
Medical Director and nursing supervisor will monitor compliance through regular monthly clinical record reviews. |
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 the review of patient records, the facility failed to ensure provision of at least one hour of psychotherapy for two of four patient records.
The findings include:
Forty-five patient records were reviewed November 29, 2011 through December 1, 2011. Four patient records were reviewed for at least one hour of therapy per month, or as ongoing assessment indicated. Patient records # 28 and 38 did not receive the required one hour per month of group or individual psychotherapy during the third and fourth year of treatment.
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Plan of Correction
Patients in treatment during the third and fourth year of treatment will be scheduled to receive at least 1hr of psychotherapy services per month, more hours as assess by the clinician.
The clinical supervisor will review the counselor's weekly schedule to monitor all patients have been scheduled and are receiving psychotherapy services as required.
During team meetings clinical supervisors will provide training to all staff on psychotherapy services.
During weekly supervision, the supervisors will review 3 charts to assure compliance. |
715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on the review of patient records, the facility failed to ensure provision of at least one hour of psychotherapy every other month for three of seven patient records.
The findings include:
Forty-five patient records were reviewed November 29, 2011 through December 1, 2011. Seven patient records were reviewed for documentation of at least one hour of group or individual psychotherapy every other month, or as ongoing assessment indicated. Patient records # 15, 26, and 29 did not receive the required one hour of group or individual psychotherapy every two months after the fourth year of treatment.
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Plan of Correction
Patients in treatment after 4 years will receive a minimum of 1 hour of group services every other month. Clinical staff will revise their schedule and will provide a copy to their supervisor.
By 1/20/12, all clinical staff will receive training on protocol for psychotherapy services.
During weekly supervision, the clinical supervisors will complete 3 chart audits to monitor compliance. |
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 the facility policy and procedures and patient records, the facility failed to restrict the reasons for involuntary termination to those reasons allowed by regulation in one of seven patient records.
The findings include:
The facility's policy and procedures were reviewed on November 28, 2011. The facility's policy on client termination stated, "the following reasons are designated for involuntary termination:
1. The client has committed threats or acts of physical violence in or around the methadone project premises.
2. The client has sold, distributed, or possessed, in or around the methadone project premises, controlled substances without lawful prescriptions;
3. The client has been excessively absent from the methadone project."
Excessive absenteeism is not a reason recognized by the Department for involuntary termination.
Forty-five patient records were reviewed November 29, 2011 through December 1, 2011. Seven patient records were reviewed for involuntary, or therapeutic, discharge. One patient record contained documentation of the patient being discharged for reasons other than those listed by regulation.
Patient # 41 was terminated from the program for excessive absenteeism on October 17, 2011.
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Plan of Correction
The facility policy on patient termination will be revised to remove excessive absenteeism as a reason for involuntary termination. Staff will discuss with the Program Director prior to giving notice of termination to any patient. The program director is responsible for reviewing termination notices and approving process to continue.
By 1/30/12, clinical supervisors will provide all staff with two in-services on the revised termination policy to follow. Program director and clinical supervisors will monitor for compliance. |
715.22(b) LICENSURE Patient grievance procedures
(b) The procedure shall permit aggrieved patients a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director. If the grievance is filed against the narcotic treatment program director, the review of the case shall be conducted by either a multi-representative group of the narcotic treatment program or a subcommittee of the governing body instituted for the express purposes of grievance adjudication.
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Observations
Based on review of the administrative documentation of patient grievances, the facility failed to document the outcome of the patient grievances in three of four grievances reviewed.
The findings include:
The facility's policy and procedure manual was reviewed on November 28, 2011. According to the facility's policy, after the program director reviews the complaint or grievance, it is referred to the appropriate clinical supervisor to address the issue. After interviewing all parties concerned, the clinical supervisor informs the client of the decision, notes on the back of the form the action taken and returns the complaint form to the program director. The facility failed to document the outcome of the grievances for patient records # 31, 32, and 33.
Patient # 31 filed a complaint July 19, 2011 because the dosing nurse refused to dose him "for no reason". An outcome of the grievance investigation was not documented.
Patient # 32 filed a complaint July 27, 2011 against a counselor. An outcome of the grievance investigation was not documented.
Patient # 33 filed a complaint August 12, 2011, reporting a counselor complaint, but an outcome was not documented.
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Plan of Correction
Effective immediately all staff will follow the policy and procedure on patient grievance. The patient's grievance is received and reviewed. The patient is informed of the decision. The outcome of the grievance is documented on the grievance form and filed in the grievance book.
By 1/20/12, the program director and clinical supervisors will provide all staff with training on the policy and procedure for patient grievance.
The program director will be responsible for reviewing the grievance book on a monthly basis to assure that all grievance outcomes have been properly addressed and documented. |
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 the annual physical with a re-evaluation by the physician in eight of twenty-one patient record reviewed.
The findings include:
Forty-five patient records were reviewed November 29, 2011 through December 1, 2011. The facility failed to document the results of an annual physical examination by the narcotic treatment program in patient records # 22, 24, 26, and 45. The facility documented late annual physical evaluations in patient records # 7, 9, 28, 33, and 41.
Patient # 7 was admitted 9-10-08. The annual physical exam was completed on 11-3-2011. This examination was seven weeks late.
Patient # 9 was admitted 7-9-09. The annual physical exam was completed on 9-29-2011. This examination was eleven weeks late.
Patient # 22 was admitted 10-20-09. The last annual physical exam was dated 11-12-2010.
Patient # 24 was admitted 10-25-1991. The last annual physical exam was completed on 11-19-10.
Patient # 26 was admitted 10-27-2000. The last annual physical exam was completed on 11-15-2010.
Patient # 28 was admitted 12-19-2008. The last annual physical was documented on 12-8-2009. The annual physical was due 12-8-2010. The annual physical was documented on 3-31-2011. This was documented fifteen weeks late.
Patient # 33 was admitted 8-18-2004. The annual physical was documented on 9-12-2011. This was documented three weeks late.
Patient # 41 was admitted 12-6-2007. The annual physical was documented on 1-3-2011. This was documented four weeks late.
Patient # 45 was admitted 10-2-1997. The last annual physical was documented 10-26-2010.
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Plan of Correction
On a monthly basis, the nursing staff together with the physician assistant will schedule appointments for the patients due for annual physical exams.
The patient will receive a message on the AVATAR system informing him/her of the scheduled appointment.
The medical director will assure that all annual physical exams and re-evaluations are completed and filed in the patient's record.
By 1/20/2012, the medical director will provide training to nursing staff and physician assistant on protocol for completing annual physical exam.
Program Director and clinical supervisors will complete chart audits at random to monitor process is being followed. |
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 all of the required components in the aftercare plan in two of two patient records.
The findings include:
Forty-five patient records were reviewed June November 29, 2011 through December 1, 2011. Two patient records reviewed successfully completed the program and required aftercare plans. The facility failed to document goals with measurable time frames in patient records # 13 and 22.
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Plan of Correction
The aftercare plan form will be revised to include a section for goals with measurable time frame. By 1/30/12, the form will be revised and all clinical staff will receive two in-services on aftercare documentation. The Clinical Supervisors and Program Director will review all successful discharges at random to ensure the aftercare plan form is being completed accurately. |
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 five of twelve patient records reviewed.
The findings include:
Forty-five patient records were reviewed November 29, 2011 through December 1, 2011. Twelve patient records required documentation of an attempt or completion of a follow up contact. The facility failed to document follow-up in patient records # 16, 20, 23, 35, and 38.
Patient # 16 was admitted on December 6, 2010 and was discharged on March 18, 2011. Per facility policy, a follow-up letter would be sent thirty-days post discharge. A follow-up contact was due by April 18, 2011. Follow-up was not documented in the patient record at the time of the inspection.
Patient # 20 was admitted on October 1, 2007 and was discharged on September 26, 2011. Per facility policy, a follow-up letter would be sent thirty-days post discharge. A follow-up contact was due by October 26, 2011. Follow-up was not documented in the patient record at the time of the inspection.
Patient # 23 was admitted on August 20, 2010 and was discharged on March 18, 2011. Per facility policy, when a patient is referred to another program a follow-up contact will take place within seven days of the transfer. A follow-up contact was due by March 25, 2011. The seven day follow-up was not documented in the patient record. The facility did document a 30 day follow-up letter in this record.
Patient # 35 was admitted on May 21, 2009 and was discharged on October 3, 2011. Per facility policy, a follow-up letter would be sent thirty-days post discharge. A follow-up contact was due by November 3, 2011. Follow-up was not documented in the patient record at the time of the inspection.
Patient # 38 was admitted on February 4, 2008 and was discharged on July 21, 2011. Per facility policy, a follow-up letter would be sent thirty-days post discharge. A follow-up contact was due by October 26, 2011. Follow-up was not documented in the patient record at the time of the inspection.
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Plan of Correction
The facility will complete and document follow up on all discharged patients. The clinical coordinator is responsible for completing follow-up on all discharged patients. Once the follow up is completed, it will be documented in the discharge summary form by the clinic coordinator. By 1/20/12, the clinic coordinator will receive training on protocol for follow-up. On a monthly basis the program director will review 3 discharged records to assre this protocol is being followed. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on the review of administrative documentation, the facility failed to provide documentation of incident reports involving complaints of patient abuse (physical, verbal, sexual , and emotional) to the Department.
The findings include:
Administrative documentation that included the unusual incident reports was reviewed November 28, 2011. It was noted the facility had documentation of an incident that identified patient # 43 had filed a grievance on August 16, 2011 regarding sexual harassment by an employee. The documentation included information of the investigation and who was involved. The employee was not terminated; however, he was removed from the unit and was reassigned. This unusual incident was not reported to the Department as required.
This was discussed with facility staff who acknowledged it was not sent.
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Plan of Correction
The facility will report all unusuaual incidents to the Dept. of Health within 48hrs of the occurence.
By 1/20/12, the program director will prvide an in-service training to all clinical staff on the policy procedure of reporting unusual incidents.
To assure compliance, all unusual incident reports will be review and handle by the program director.
The Program Director and Clinical Supervisors will be responsible for assuring this protocol is being followed.
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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to keep the grounds of the facility safe and in good repair at all times for the safety and well-being of residents, employees and visitors.
The findings include:
The employee and visitor's parking area was observed on November 29, 2011 through December 1, 2011. The employee and visitors' parking lot was unsafe and in poor condition at the time of inspection.
The parking lot was unsafe due to the asphalt being uneven and having many potholes. Because of the size and number of potholes, it is hazardous to walk in the parking lot, and it is also impossible for drivers to avoid the potholes when driving in the parking lot.
The findings were confirmed by the facility director on December 1, 2011.
This is a repeat citation from the August 17, 2011 licensing inspection.
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Plan of Correction
The facility has hired a contractor to make repairs to the visitor's and employee parking lot. The lot will be closed for repairs on Thursday, December 22, 2011 and Friday, December 23, 2011. All repairs have been completed as of December 23, 2011.
The Director of Facilities Management will be responsible for supervising and maintaining the parking lot and all facility grounds. The director of Facilities Management will also be responsible for making rounds at random to ensure all grounds are being maintained in good condition. |