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 January 31 and February 1, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Progressive Medical Services, Inc - Houston was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on February 28, 2008.
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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 14 patient records, the facility failed to document patient specific current dependency. Specifically, patient # 2's record contained documentation on a form that stated current dependency was verified by the urine drug screen; the document was signed by the physician on 10/11/07 but the urinalysis results were not received by the facility until 10/12/07. Another patient's current dependency was determined by the physician's assessment and documentation of "sneezing" with no other documentation to establish current dependency.
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Plan of Correction
On February 6, 2008 director met with medical director and discussed documenting a person's current dependency. Director informed MD that his assessment of an individual's dependency will need to be more detailed. MD agreed to complete a more detailed assessment.
A new medical documentation of addiction form was introduced that allows for the urine result to be added, dated when it was reviewed by the MD.
The clinic does have the urine result before starting a client, the MD does review the urine result but the way the form was written it did it did not show these actions. The new form reflects our process and allows for more specific documentation. The new form was implemented February 6, 2008.
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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
The facility failed to address in their policy and procedures that documentation of current dependency is required at readmission.
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Plan of Correction
On February 4, 2008, Director completed a review of our policy and procedure manual. Specifically reviewing documentation of current dependency upon readmission, policy was corrected to include that current dependency is required at readmission
On February 6, 2007 management staff reviewed readmission process with Director to ensure staff understanding of procedure
The management staff completed a review of clients who were readmitted into treatment under this standard within the last year. Upon review of these charts, we did not admit anyone without determining current dependency.
Director believes that all staff were trained and understood the procedure for readmissions under six months as stated by regulation and that the manual's policy was written incorrectly
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715.10(c) LICENSURE Pregnant patients
(c) Counseling records and other appropriate patients records shall reflect the nature of prenatal support provided by the narcotic treatment program.
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Observations
Based on a review of 22 patient records, patient # 8 was pregnant, however, her treatment plan failed to address the pregnancy and prenatal support.
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Plan of Correction
A training process has been created to assist clinical staff with developing useable, measurable goals specific to their client and the client's needs. It is detailed in a plan of correction regarding a citation we received for treatment plans.
The director did address this citation with staff on February 6, 2008. Discussed how pregnancy should be addressed in the client's treatment plan(s) and gave examples of goals that would be appropriate to use.
All staff understood the reasoning. Clinical staff are aware of clients who are pregnant and will monitor treatment plans submitted for these women and ensure that pregnancy is being addressed in the plans.
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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
Observation of the methadone dispensing revealed that the facility failed to ensure patient confidentiality. The returned take-home bottles that included the patient's full name, the number of milligrams of methadone, the prescribing physician's name and the facility name were discarded in a non-secured trash container.
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Plan of Correction
During management meeting on February 6, 2008 this issue was discussed and it was determined that the clients will need to use a black sharp pen and cross off their personal information on each bottle returned at the nursing window.
All staff were informed of this change and clients were informed of this change at the dosing window, in the monthly newsletter and when in session with their primary counselor.
We began to use this process to ensure client confidentiality on February 7, 2008.
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715.16(a)(5) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(5) A narcotic treatment program shall develop written policies and procedures relating to granting and rescinding take-home medication privileges.
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Observations
The facility failed to develop a policy and procedure for patient call backs that was consistent with the requirements of the exception. Specifically, facility policy specified quarterly callbacks for the first year with twice a year callbacks in subsequent years; the exception requires quarterly call backs in all circumstances. Additionally, there was no documented facility policy to address the impact on take-home privileges for a urine drug screen that was positive for illicit drugs.
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Plan of Correction
On February 4, 2008 director and medical director reviewed current take home policy. We used the state regulations and compared our written policy to ensure compliance.
Although a process was documented regarding a client producing an illicit urine profile, we expanded this to allow for very specific guidelines to use when dealing with illicit urines and clients take homes especially under an exception.
Also, all clients who have extended take homes have had the required amount of call backs as defined by state standards. The policy/procedure was amended to reflect this process.
All staff were given a written copy of our updated take home medication policy on February 6, 2008. The changes were presented and discussed by director and MD with the staff to ensure understanding of the standard/procedures.
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715.17(c)(2) 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:
(2) Drug storage areas. A narcotic treatment program shall develop and implement written policies and procedures regarding storage of medications and access to the medication storage area. Agents shall be stored in a locked safe that has been approved by the DEA under 21 CFR 1301.72 and 1301.74 (relating to physical security controls; and other security controls).
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Observations
During onsite inspection conducted on January 31, 2008, the doors to the methadone dispensing area were left open, allowing full access to anyone wanting to enter the dispensing area. The dispensing area must be secured at all times with access to the area limited to designated staff.
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Plan of Correction
This was reviewed with all staff on January 31, 2008 by director.
Medical staff were reminded that all doors must be locked at all times. The staff really did not have any reason to why security protocol was not being followed.
On February 1, 2008 Director had locks changed on specific doors that were used by clinical staff that are close to the nursing station.
Director checked to make sure all staff have keys to enter building areas that they are allowed to be in and were reminded that they need to use keys and make sure doors are locked.
Director made and will make random checks to make sure doors are locked and ask for staff members keys to make sure they are maintaining security procedures.
Also, the director has requested to have nurses station window covered with a "teller" like window allowing for space at the bottom for nursing staff to give clients their dose, thus giving even less access to the nursing station area. This window is scheduled to be in place by February 25, 2008.
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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 14 patient records, patients # 1 ,2 ,6, 13 and 14 did not receive the minimum 2.5 hours of psychotherapy per month. The treatment plans for these patients required 2.5 hours of counseling per month.
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Plan of Correction
The charts identified during the inspection were reviewed by director on February 6, 2008. The primary counselors of each client met with director to discuss why sessions were not held. Director and primary counselors completed a case consultation that discussed a plan to make sure client gets the minimum amount of counseling time required by state standards.
Director instructed clinical supervisors to complete case consults with the counselor for any clients who miss session time, thus giving the counselor a plan to ensure clients attend scheduled sessions.
Director held a staff meeting on February 6, 2008 with all clinical staff to discuss difficulties they are having with ensuring certain clients receive the minimum amount of counseling hours.
Counselors and clinical supervisors were reminded to use verbal warning documentation with clients who miss their scheduled session and that session should be rescheduled for these clients. Our current process for dealing with missed sessions appears to still work counselors will need to be consistent with using it.
Once issue was identified that will need to be dealt with by director. Since we have quite a few clients that use county transportation, the drivers do not always wait for clients to complete their appointments at the facility. Some clients have been left at the facility and would not have a van to pick them back up to return home until late in the afternoon. Thus they have had to spend hours at the clinic, which is not productive for the client or the clinic. Also, it causes the counselors to either have to schedule weekly sessions with these clients or reschedule clients because the client does not want to be left without a ride.
The director will contact Washington county rides and discuss issues we are having and what can be done to correct them. Director did speak to Washington county staff on February 8, 2008 explained the problems and director is still waiting for a response.
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715.21 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.
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Observations
Based on random review of 14 patient records, the facility failed to ensure all efforts had been initiated to retain the patient prior to the involuntary termination. Patient # 14, was involuntarily discharged August 2, 2007 for failure to follow her treatment plan, specifically for not maintaining financial obligations to the facility. Additionally, patient # 9 received a notice of involuntary termination for failure to follow her treatment plan (financial obligations); record documentation included information that the patient identified financial difficulties. Patient # 10 was assessed for readmission on March 15, 2007; documentation in the assessment contained a statement that the patient was previously discharged for financial reasons. A review of patient records did not indicate the patient was provided with treatment options (to address her inability to pay) prior to her notice of termination.
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Plan of Correction
The director with the assistance of management staff has recreated the process of involuntary detoxification notices. First, all reasons for termination from treatment has been updated to ensure compliance with the four reasons to why a client could be detoxed from treatment.
We recreated forms and our process so that a client who has any issues with treatment has a few steps that they may use to assist with correcting these issues or finding a form of treatment that better suits their needs. As well as allow staff to document the amount of work they did with the client in solving the problem
The first step is notification of the problem, the primary counselor and/or the clinical supervisor will meet with the client to discuss our concerns and make an attempt to assist the client with solving the problem.
If this would not provide a resolution we would move on to the next step which would require the client to schedule a meeting with the intervention committee. At this meeting information will be gathered to determine what the client needs are so staff are able to assist with the resolution of the problem.
A written plan that would assist the client with solving issue (s) will be given to the client (the plan will be discussed with the client to ensure understanding and all present would sign the plan) at that time. Along with this plan any referrals recommended by the intervention committee would be given to the client.
The primary counselor will assist the client is meeting goals of the plan.
If the client fails to follow/successfully complete the intervention plan the next stop will be a notice of appeal. At this meeting, again the staff will work with the client to find out their issues/concerns, develop a plan to help correct the problem so client could avoid detoxification.
These plans will have specific dates that certain goals will need to be met by the client.
We have created an information form that will be given to all clients that includes medical assistance numbers, addresses, clinic addresses, list of drug free treatment facilities and county SCA offices.
Staff were trained and this new process was implemented on February 18, 2008.
We do believe we work with all of our clients a great deal to keep them in treatment. This process allows us to work with the clients, document all of our work that we do with the clients, takes away clients anxiety regarding being detoxed and gives the client a useable plan and information that could assist in continuing their treatment.
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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 a review of program documentation and policies and procedures, the facility failed to develop reasons for possible termination that were consistent with the standards. Specifically, facility policy exceeded the standards and included the following reasons for termination: loitering, property destruction, altered urine specimen, missed counseling appointments, and attempting to remove methadone from the building. Additionally, financial obligations were identified as treatment goals and were utilized as reasons for involuntary termination. Treatment goals must be developed with consideration of patient ability and evaluation of progress must document an ongoing assessment of patient ability.
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Plan of Correction
There were two areas the facility was cited for regarding termination of client's treatment and the plan created for resolution is detailed in prior plan of correction.
The director with the assistance of management staff has recreated the process of involuntary detoxification notices. First, all reasons for termination from treatment has been updated to ensure compliance with the four reasons to why a client could be detoxed from treatment.
We recreated forms and our process so that a client who has any issues with treatment has a few steps that they may use to assist with correcting these issues or finding a form of treatment that better suits their needs. As well as allow staff to document the amount of work they did with the client in solving the problem
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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 a review of 14 patient records the facility failed to provide any substantiation or factual information to support the counselor's assessment. Counselors utilized the word "appears" in lieu of making a definitive statement.
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Plan of Correction
During staff meeting on February 6, 2008 director addressed this with counseling staff.
The director will meet with counselors once a week at which time a review of a client chart will be conducted, progress notes will be reviewed and discussed, and counselors will be given suggestions in documenting client information. This will begin the week of February 18, 2008 and will continue for at least two months.
Clinical supervisors will be part of these meetings, after the two month period they will take over these weekly meetings and this will become part of our on-going training program for clinical staff.
Clinical supervisors when completing 90 days review of charts will pay special attention to the use of these words in the counselor's documentation, they will document its use on our chart review forms, discuss with the counselor and will add assessment writing to the counselor's individual training plan.
ATTC does offer on line courses and the director is in the process of identifying courses that relate to assessment skills and writing. At this time there is not a course available to address assessment skills but director will continue to seek out additional training that can be offered to staff.
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715.23(d)(1) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(1) The treatment plan shall identify the behavioral tasks a patient shall perform to complete each short-term goal.
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Observations
Based on a review of 14 patient records, patients # 1, 2, 5, 6, 7, 8, 9, 10, 11 and 13 had short term goals in their treatment plans that did not address measurable steps.
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Plan of Correction
The facility has been working on treatment plan goals with staff for some time. Director and Clinical supervisor are signed up for an on line treatment planning course sponsored by ATTC. The class was supposed to begin in January 2008 but has been delayed until the spring. Director is in contact with the local ATTC office; staff are paid and registered for the class.
We hope that this course gives management staff some ideas of how to assist the clinical staff in writing treatment plan goals.
Also, Director has obtained a three part series created by ATTC in 2006, regarding treatment planning. It is series 22 and has three parts, "creating a living document", "make a smart plan" and "putting it all together". Director and clinical supervisor have reviewed the information have decided to use the information as an in house training for clinical staff.
For three weeks, one part of the series will be given to clinical staff in an in house in-service training each week.
This series provides exercises and a quiz at the end. The first training will begin the week of February 18, 2008; the whole training will be completed by the week of March 3, 2008. Staff will be required to complete an in-service evaluation which will be given to the director to determine if it was helpful to them.
Again we are hoping that this helps clinical staff gain a better understanding in treatment planning.
Clinical supervisor reviews each plan and has been meeting with staff to discuss their treatment plans on a weekly basis. Plans are being returned to counselors if the goals and steps are not able to be measured.
The development of treatment plans continues to be part of clinical staffs individual training plans thus is discussed often.
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715.23(d)(2) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Based on a review of 14 records, the facility failed to document new patient goals or objectives in the treatment plan updates that were realistic and specific to patient needs, specifically patients # 2, 3, 5, 7 and 13.
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Plan of Correction
This relates to previous citation for treatment plans and we are hoping that the plan of correction we have created for that citation will assist the clinical staff with this citation so they will be able to write specific new patient goals that are realistic and specific to their individual clients needs.
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