INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the February 19, 2010 methadone monitoring inspection. The follow-up inspection was conducted on November 9, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Aldie Foundation, Inc. was found not to be in compliance with the applicable chapters of 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 4, 2010.
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Plan of Correction
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715.10(d) LICENSURE Pregnant patients
(d) Within 3 months after termination of pregnancy, the narcotic treatment physician shall enter an evaluation of the patient 's treatment status into her record and state whether she should remain in comprehensive maintenance treatment or receive detoxification treatment.
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Observations
Based on the review of patient records, the facility failed to ensure the physician entered into the patient record an evaluation of the patient's treatment status within 3 months after the termination of the pregnancy in one of two patient records.
The findings include:
Eight patient records were reviewed on November 9, 2010. Two patient records required the physician's evaluation of the patient's treatment status. Patient # 2 was admitted for treatment October 28, 2010. The patient entered treatment because she was pregnant. The pregnancy terminated with the baby's birth on February 16, 2010. There was no documented evaluation by the physician stating whether the patient should remain in maintenance treatment or receive detoxification treatment.
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Plan of Correction
A checklist is in place at the facility to document coordination of care for pregnant women. The Medical Director and the Program Coordinator have revised this checklist to include evaluation by narcotic treatment physician within 3 months of termination of pregnancy. Protocol has been amended to flag electronic dosing files to calendar patients for appointment with NTP Physician within 3 months of termination of pregnancy. Physicians are provided with a form and format for clearly documenting their clinical assessment with statement of whether patient should remain in maintenance treatment or receive detoxification treatment. The Program Coordinator and the Medical Director will maintain oversight that this documentation is in the clinical record of each pregnant patient and will insure compliance with this regulation through Quality Assurance review of charts. Charts reviewed by DDAPL staff have been brought into compliance |
715.17(b) LICENSURE Medication control
(b) A narcotic treatment program shall develop policies and procedures regarding verbal medication orders, including the issuing and receiving of orders, identifying circumstances when orders are appropriate and documenting orders, in accordance with applicable Federal and State statutes and regulations.
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Observations
Based on the review of patient records the facility failed to ensure the physician dated the signature after submitting a verbal order in two of three patient records reviewed.
The findings include:
Eight patient records were reviewed November 9, 2010. Three records contained documentation of a physician's verbal orders.
Patient record # 5 contained a verbal order dated October 6, 2010. The physician signed, but there was no date to demonstrate it was signed within 24 hours as required. There was a verbal order documented on August 21, 2010 that was not signed or dated.
Patient record # 6 contained a documented verbal order on July 20, 2010. It was signed and had a stamped date of July 22, 2010. On September 3, 2010 there was a verbal order with a signature and a stamped date that was not decipherable to determine when it was signed.
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Plan of Correction
Written Policy and Procedure is in place to meet Federal and State statutes and regulations. The Program Coordinator has reviewed these policies and procedures with the Medical Director. To insure compliance, all NTP Physicians and Locum Tenens Physicians supporting the NTP will be oriented that verbal orders be signed and dated within the time specified by the facility's written policy. The Nursing Manager will complete a training for dispensing nursing staff by 12/06/10 re: agency policy for signing of verbal orders. The Program Coordinator and the Medical Director will maintain oversight and insure compliance with this regulation through Quality Assurance review of charts. |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on the review of patient records and administrative documentation, the facility failed to ensure the psychosocial evaluations were completed within the policy-stated 30 days of admission.
The findings include:
Eight patient records were reviewed on November 9, 2010. Three patient records were reviewed for psychosocial evaluations.
Patient # 4 was admitted September 24, 2010. An evaluation had not been completed at the time of the inspection.
Patient # 5 was admitted August 20, 2010. An evaluation had not been completed at the time of the inspection.
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Plan of Correction
The facility has integrated a newly revised psychosocial form for patients' records, to better comply with regulation 715.23 (b)(15). The Pharmacotherapy Coordinator will provide a refresher training for the Pharmacotherapy counseling staff addressing clinical documentation utilizing this new format on or by 12/30/2010, with attention to reviewing clinical assessment and timely execution of documentation as outlined by the facility's policy. The Pharmacotherapy Coordinator will monitor and ensure program staff's compliance with completing the psychosocial evaluations within 30 days of admission by utilizing the AMS computer program to generate monthly listings of due dates for the psychosocial evaluation form, and then confirming the timely completion of the form with the assigned primary therapist for each new client. Charts reviewed by DDAPL staff have been brought into compliance |
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 patient records and discussion with the program coordinator, the facility failed to document the progress or lack of progress in achieving the goal statements from the prior treatment plan in two of two patient records.
The findings include:
Eight patient records were reviewed November 9, 2010. Two patient records were reviewed for treatment plan update documentation.
Patient record # 3 had a comprehensive treatment plan completed may 26, 2010. There was no treatment plan update of this comprehensive treatment plan at the time of the inspection.
Patient record # 6 had a comprehensive treatment plan completed August 4, 2010. There was no treatment plan update of the comprehensive treatment plan at the time of the inspection.
The program coordinator attempted to locate the updates, but reported there were none found.
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Plan of Correction
Written Policy and Procedure is in place at the facility to meet the Federal and State statutes and regulations for Treatment Plans. The Pharmacotherapy Coordinator will provide supervision for Pharmacotherapy counseling staff addressing the proper execution of treatment plans with regard to timeliness and to providing treatment plan updates meeting the standards required by Chapters 157,709, and 711. The Pharmacotherapy Coordinator will maintain oversight for completeness through Quality Assurance reviews of charts and during case consults in individual supervision with clinicians. The Program Coordinator will review filing protocols with the Office Manager to assure that all documentation is present in each patient's chart. |