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 and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on December 1 through December 3, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Aldie Counseling Center was found not to be in compliance with the applicable chapters of 4 PA Code and 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on December 24, 2009.
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Plan of Correction
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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 record documentation, the facility failed to ensure the physician documented in the patient record the rationale for granting take home medication in three of three patient records.
The findings include:
Twenty two patient records were reviewed on December 1-3 2009. Three records were reviewed for take home medication documentation. Patient records #17, 18 and 19 did not have the physician's rationale for granting the take home medication but simply stated "as noted" or "approved".
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Plan of Correction
Narcotic Treatment Physician will document on every take-home form with his rationale for granting the take-home privilege. Case Consults are conducted with every take-home request and include comments and/or concerns from every team member including the Doctor regarding request for take home medication. Program Coordinator will review each take-home request form and case consult for substance and completion before signing off on each form. This protocol will begin 12/29/09. |
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 one of seven patient records reviewed.
The findings include:
Twenty-Two patient records were reviewed on December 1-3, 2009. Seven patient records were reviewed for completed laboratory tests as part of the admission process, specifically a tuberculosis Mantoux test (PPD).
Patient record # 9 was transferred in the facility May 4, 2009 and the transferring facility sent documentation (dated in 2008) of the patient having had a positive PPD in the past with the last chest x-ray having been obtained in 2006.
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Plan of Correction
The Program Coordinator will ensure that all laboratory tests or other special examinations are conducted at the time of admission for all clients regardless of receipt of any prior documentation from other agencies. Program Coordinator will review all admission client records within the first month to assure compliance. Protocol to begin January 15th, 2010. |
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 in two of three patient records.
The findings include:
Twenty two patient records were reviewed December 1-3, 2009. Two patient records were reviewed for annual evaluations.
Patients # 10 and 11 did not have an annual evaluation completed.
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Plan of Correction
Further training will be provided to all clinicians on protocols in place to maintain compliance with every patient receiving an annual evaluation by their counselor. The counselor is identified to maintain a spreadsheet/checklist which will track patient anniversary date, annual evaluation date and other key benchmarks. The spreadsheet and client chart will be reviewed by the program coordinator and clinician in individual supervision on a monthly basis to ensure compliance to this standard. Completion
date January 12,2010 |