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 January 20 and 21, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Freedom Healthcare Services, LLC. was found not to be compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and a plan of correction is due on February 13, 2010. .
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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 and staff interviews, the facility failed to provide documentation of physician determinations of patient dependency and drug and alcohol histories that were specific to the individual patient in four of six patient records.
Findings:
Patient records were reviewed on January 20 and 21, 2010. Six methadone records were reviewed for documentation pertaining to the physician's evaluation of the patient following a face-to face assessment. Four patient records failed to document an assessment that specifically addressed the patient's current dependency and history of addiction.
The facility utilized a form that the physician completed for the purpose of documenting the determination of current dependency and history of addiction. The form provided a checklist for the physician to indicate observations and assessments for each patient.
Patient record # 1; all items listed on the checklist were checked as applicable to this patient. This included checking a line on the form that specified that the patient had current tract marks and other indications of current use. Patient # 1 was a transfer patient from another facility; documentation in the patient record did not identify current use.
Patient record # 2; the only areas specified on the checklist identified "patient statement to doctor". There was no additional information that specifically addressed the patient's current status and history.
Patient record # 3; the only areas specified on the checklist identified "patient statement to doctor" for drug and alcohol history and results of drug testing for current dependency. There was no additional information that specifically addressed the patient's current status and history.
Patient record # 4; the only areas specified on the checklist identified "patient statement to doctor" for drug and alcohol history and results of drug testing and "patient statement to doctor" for current dependency. There was no additional information that specifically addressed the patient's current status and history.
Interviews with administrative staff acknowledged the importance of the physician's inclusion of information specific to the patient. The facility director emphasized that efforts are current to assist the facility's physician with the inclusion of more specific documentation in the patient assessments.
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Plan of Correction
On 1/25/2010, the Project Director/Facility Director and clinical supervisor met with both of the physicians at Freedom Healthcare. It was reviewed with them the findings of the audit. The Project/Facility Director reviewed documentation of addiction form with each physicians and explained the purpose of the form. The Project/Facility Director will review every Monday the medical charts with each of the physicians.
To ensure that this deficiency does not happen, the Project/Facility Director will regularly audit the medical charts to make sure the form is being completed correctly. |
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 and a staff interview, the facility failed to contact the previous facility for the patient's treatment history in one of three patient records reviewed.
The findings include:
Five patient records were reviewed January 20 and 21, 2010. Three patient records required contacting the prior treatment facility for the prior treatment history. Two of the patient records contained information that indicated a transfer from another facility and information from the former narcotic treatment facility was included in the patient record. Patient record # 3 included documentation that the patient had previously attended two narcotic treatment facilities. There was no documentation of any attempt to obtain the patient's prior treatment history from the prior treatment facilities.
The issue was addressed with the facility director on January 21, 2010. The facility director confirmed there was no documentation of prior treatment history in patient record # 3 and further acknowledged that this information should have been included in the patient record.
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Plan of Correction
The Project Director/Facility Director reviewed with all staff the findings of the audit on 1/21/2010. All staff were advised that they must try to obtain releases of information for other treatment facilities. Freedom Healthcare currently has an intake coordinator on staff who is responsible for obtaining those previous treatment releases of information at intake. Freedom Healthcare did not have the postion of intake coordinator previously but had all of the clinical staff completing intakes. This information was reviewed with the intake coordinator on 1/21/2010 as to ensure that it is part of the intake process. Any omitted information that the primary counselor receives from client after their intake is completed will be the responsibility of the primary counselor to obtain. The clinical supervisor will continue to monitor that this is being done during regular reviews of charts. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records and a staff interview, the facility failed to provide an appropriate dosage level in four patient records.
The findings include:
Patient records were reviewed January 20 and 21, 2010. Patient record reviews for patients receiving suboxone medication revealed that the facility physician was prescribing suboxone with the instruction that the suboxone tablets could be halved. A Suboxone tablet is not to be halved or scored. A staff interview concluded that staff were aware that medication prescriptions were not to be issued with doses that indicated the tablet was to be split. Staff interviews conducted on January 21, 2010 revealed that the facility was aware doses should not be prescribed that specified tablets be halved.
This is a repeat citation; the facility was previously cited on July 23, 2009.
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Plan of Correction
On 1/25/2010, the Project Director/Facility Director reviewed with both physicians how they were prescribing suboxone doses. It was explained to the physicians that client doses must be prescribed in either 8mg tablets or 2mg tablets as recommended and that suboxone pills cannot be halved. Both physicians were advised that this conversation would be documented in their personnel charts and that if it were to occur again then they would follow Freedom Healthcare's disciplinary process. The Project Director/Facility Director reviewed the manufacturer's guidelines as well as the Federal guidelines for prescribing suboxone.
In order to ensure that this deficiency does not reoccur, the Project Director will review medical charts every Monday with the physicians. The Project/Facility Director will monitor the compliance of this to ensure that the physicians are not writing prescriptions in a manner that the suboxone tablets should be halved. |
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 three of six records.
The findings include:
Six patient records were reviewed January 20 and 21, 2010. Three patient records failed to document the required minimum of 2.5 hours per month.
Patient record #1 contained documentation of 2 hours of therapy in December 2009, 2.75 hours in November 2009, and 1.25 in October 2009 for an average of two hours per month.
Patient record # 3 contained documentation of 1 hour of therapy in December 2009, 4 hours in November 2009, and 1.5 hours in October 2009 for an average of 2.2 hours per month.
Patient record # 4 contained documentation of 1.25 hours of therapy in December 2009, 2 hours in November 2009, and 2 hours in October 2009 for an average of 1.75 hours per month.
This is a repeat citation; the facility was previously cited July 23, 2009.
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Plan of Correction
The Project Director/Facility Director has hired another counselor that began employment on 1/28/2010. Also, one of the counselors that was on medical leave returned on 1/25/2010. The recent hire, return of the other counselor from medical leave and the 35:1 ratio for each caseload will help Freedom Healthcare to ensure that the counseling requirement is being met. The Project Director/Facility Director met with staff on 1/21/2010 and reviewed findings of the audit. The Project Director/ Facility Director advised the clinical staff that the minimum requirement of 2.5 hrs of counseling per month must be met. The clinical supervisor will continue to monitor that the counseling requirement is being met by regularly reviewing the clinical charts. |