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 April 22-24, 2014 by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the findings of the on-site inspection Kirkbride 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.
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Plan of Correction
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715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on the review of patient records, the facility failed to verify the identity of the patient prior to the administration of a narcotic agent in three out of twelve patient records.
The findings include:
Twelve patient records were reviewed on April 22 through 24, 2014. All patient records were specifically reviewed for patient identity information. Patient records # 5, 6, and 12 did not contain documentation of the verification of the patient's identity.
The findings were reviewed and confirmed with the project director and clinical director.
This is a repeat deficiency from the 5/15/2013 on-site review.
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Plan of Correction
The admissions department will identify any opiate addicted clients and will create a daily list of any clients eligible for methadone that do not have appropriate identification. This list will be provided to the unit to clerk in order to maintain a list of any clients that are not eligible for methadone treatment prior to receipt of identification. This list will be updated daily as clients are assisted with obtaining proper identification and will be provided to the treating physicians on a daily basis to ensure that only clients with identification will be initiated on methadone. This process will be monitored on a bi-weekly basis for a 6 month period by the compliance mentor and compliance director to ensure that it is completed appropriately and that only eligible clients are started on methadone. The results will be reviewed on a monthly basis at the chemical dependency dashboard. The executive director will then report non-compliance at the quarterly board of directors meeting. The agency will establish full compliance by 7/1/2014. |
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 three out of three patient records reviewed.
The findings include:
Twelve patient records were reviewed on April 22 through 24, 2014. Three patient records contained information that indicated prior narcotic treatment episodes and this required the facility to contact the prior narcotic treatment facility for the previous treatment history that was reported by the patient, specifically patient records # 4, 6 and 7.
The findings were reviewed with the project director, facility director, clinical director, clinical supervisor, medical director and management. The findings were not disputed.
This is a repeat deficiency from the 5/15/2013 on-site review.
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Plan of Correction
Methadone Coordinator will meet with every new 3B client who is on MMT and request client to sign release of information for every past narcotic treatment program. Methadone Coordinator will fax request for collateral information to each treatment program and document these requests and correspondence. On our psychiatric unit the Unit Clerk will meet with every client who is on MMT and request the patient sign releases of information to obtain treatment histories for past NTP(s). Unit Clerk will fax these requests for collateral information to the appropriate NTP(s) and document that these requests and correspondence have occurred in the patient record. The compliance mentor and director will audit a sample of methadone charts on a bi-weekly basis for a 6 month period. The results of the audits will be reported to the chemical dependency and psychiatric hospital dashboard as well as to the program director. The agency will be in full compliance by 7/1/14. |
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 obtain a complete initial drug-screen urinalysis from a CLIA and Department of Health approved laboratory in nine of twelve patient records.
The findings include:
Twelve patient records were reviewed for the completion of an initial drug-screening urinalysis prior to the administration of a narcotic agent on April 22 through 24, 2014. Nine of these records failed to include documentation of a urinalysis screen prior to administering the initial methadone dose, specifically patient records # 1, 2, 3, 4, 5, 6, 8, 10, and 11.
Patient # 1 was admitted on April 10, 2014. The complete CLIA and Department of Health approved laboratory urinalysis results were received on April 12, 2014. The first dose of Methadone, a narcotic agent, was given to the patient on April 11, 2014. The facility failed to document a complete drug screen urinalysis prior to the administration of a narcotic agent.
Patient # 2 was admitted on April 15, 2014. The complete CLIA and Department of Health approved laboratory urinalysis results were received on April 17, 2014. The first dose of Methadone, a narcotic agent, was administered to the patient on April 15, 2014. The facility failed to document a complete drug screen urinalysis prior to the administration of a narcotic agent.
Patient # 3 was admitted on April 7, 2014. The complete CLIA and Department of Health approved laboratory urinalysis results were received on April 9, 2014. The first dose of Methadone, a narcotic agent, was given to the patient on April 7, 2014. The facility failed to document a complete drug screen urinalysis prior to the administration of a narcotic agent.
Patient # 4 was admitted on March 26, 2014. The complete CLIA and Department of Health approved laboratory urinalysis results were received on March 28, 2014. The first dose of Methadone, a narcotic agent, was administered to the patient on March 26, 2014. The facility failed to document a complete drug screen urinalysis prior to the administration of a narcotic agent.
Patient # 5 was admitted on April 14, 2014. The complete CLIA and Department of Health approved laboratory urinalysis results were received on April 15, 2014. The first dose of Methadone, a narcotic agent, was administered to the patient on April 14, 2014. The facility failed to document a complete drug screen urinalysis prior to the administration of a narcotic agent.
Patient # 6 was admitted on March 24, 2014. The complete CLIA and Department of Health approved laboratory urinalysis results were received on March 26, 2014. The first dose of Methadone, a narcotic agent, was administered to the patient on March 24, 2014. The facility failed to document a complete drug screen urinalysis prior to the administration of a narcotic agent.
Patient # 8 was admitted on March 14, 2014. The complete CLIA and Department of Health approved laboratory urinalysis results were received on March 17, 2014. The first dose of Methadone, a narcotic agent, was administered to the patient on March 15, 2014. The facility failed to document a complete drug screen urinalysis prior to the administration of a narcotic agent.
Patient # 10 was admitted on January 27, 2014. The complete CLIA and Department of Health approved laboratory urinalysis results were reviewed on January 30, 2014. The first dose of Methadone, a narcotic agent, was administered to the patient on January 28, 2014. The facility failed to document a complete drug screen urinalysis prior to the administration of a narcotic agent.
Patient # 11 was admitted on December 30, 2013. The complete CLIA and Department of Health approved laboratory urinalysis results were received on December 31, 2013. The first dose of Methadone, a narcotic agent, was administered to the patient on December 30, 2013. The facility failed to document a complete drug screen urinalysis prior to the administration of a narcotic agent.
The findings were reviewed and confirmed with the Project Director.
This is a repeat deficiency from the 5/15/2013 and 11/22/2013 on-site review.
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Plan of Correction
The agency has worked with the CLIA approved laboratory to create a new pick up schedule to ensure that all urine specimens are picked up and transported in a timely manner. The admissions department will begin to identify any clients that may be candidates for methadone treatment and their UDS will be labeled as STAT and all STAT labs will be separated for pick up by lab transport. The physician's clerk will receive all STAT lab and supply them to the physician for review prior to the initiation of methadone. The admissions manager will review the UDS requests on a daily basis to ensure that all appropriate urine drug screens are being requested and marked as STAT. The admissions manager will report any non-compliance to the executive director. The compliance mentor and compliance director will complete bi ?weekly audits of a sample of methadone charts for a period of 6 months and results will be reported monthly at both the chemical dependency dashboard as well as at the doctor's meeting. The executive director will report non-compliance at the quarterly board of director's meeting. The agency will be in full compliance by 7/15/14. |
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, the narcotic treatment program failed to document the consultation between the narcotic treatment physician determining the initial dose and the narcotic treatment physician performing the physical examination in six of twelve patient records.
The findings include:
Twelve patient records were reviewed on April 22 through 24, 2014.
The prescribing physician completes an abbreviated assessment form on back of the documentation that verifies opiate addiction and one year dependency in order to eliminate the need to document a consultation with the physician completing the physical exam.
Six of the twelve records reviewed did not include a completed abbreviated assessment form, specifically patient records # 3, 4, 6, 7, 8, and 9.
The findings were reviewed and confirmed with the Project Director.
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Plan of Correction
The medical director has provided thorough training to the new narcotic treatment physician to ensure that he is properly educated on the required documentation. The abbreviated assessment form will be completed on all appropriate clients that are eligible for methadone treatment. The compliance mentor and director will audit a sample of methadone charts on a bi-weekly basis for a period of 6 months to ensure that all documentation is appropriately completed. The results of the audit will be reported monthly at the doctor's meeting. The agency will be in full compliance by 7/1/14. |
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 that the narcotic treatment physician determined the proper dosage level in six of twelve patient records. The narcotic treatment physician must document orders in accordance with applicable Federal and State Statues and regulations.
The findings included:
Twelve patient records were reviewed for the physician's documentation in determining the proper dose. Patient records # 1, 4, 5, 6, 7 and 12 had orders documented for determining the patient's dose for multiple days without physician assessment.
Patient # 1 was admitted on April 10, 2014, and received an initial dose of 30 mg of Methadone on April 11, 2014, at 1600. Documented in the patient record was an order dated 4/11/2014, Methadone 30 mg today, 35 mg 4/12, and 40 mg 4/13 daily. There was no documentation that the narcotic treatment physician assessed the patient to determine if an increase in the patient's dose was needed.
Patient # 4 was admitted on March 26, 2014, and received an initial dose of 30 mg of Methadone on March 26, 2014. Documented in the patient record was an order dated 3/26/2014, Methadone 30 mg today, 35 mg 3/27, and 40 mg 3/28 then to be re-evaluated. There was no documentation that the narcotic treatment physician assessed the patient to determine if an increase in the patient's dose was needed.
Patient # 5 was admitted on April 14, 2014, and received an initial dose of 30 mg of Methadone on April 14, 2014, as a detoxification taper. Documented in the patient record was an order for Methadone Induction protocol dated 4/19/2014, Methadone 10 mg (30) today, Methadone 35 mg 4/20, Methadone 40 mg 4/21 daily. There was no documentation that the narcotic treatment physician assessed the patient to determine if an increase in the patient's dose was needed.
Patient # 6 was admitted on March 24, 2014, and received an initial dose of 30 mg of Methadone on March 24, 2014, as a detoxification taper. Documented in the patient record was an order for Methadone Induction Protocol dated 3/31/2014, Methadone 30 mg 3/31, 35 mg 4/1 and 40 mg 4/2 daily. An order dated 4/4/2014 noted Methadone 45 mg 4/5 and 50 mg daily 4/6. An order dated 4/10/2014 noted 55 mg today 4/10, 60 mg on 4/11 and 65 mg 4/12 daily. There was no documentation that the narcotic treatment physician assessed the patient to determine if an increase in the patient's dose was needed.
Patient # 7 was admitted on April 14, 2014, and received an initial dose of 25 mg of Methadone on April 15, 2014. Documented in the patient record was an induction order dated 4/15/2014, Methadone 25 mg 4/15, 30 mg 4/16 and 35 mg 4/17. There was no documentation that the narcotic treatment physician assessed the patient to determine if an increase in the patient's dose was needed.
Patient # 12 was admitted on November 7, 2013, and received an initial dose of 20 mg on November 11, 2013. Documented in the patient record was an order for Methadone Induction Protocol dated 11/11/2013, Methadone 20 mg 11/11 today, then 25 mg daily. There was no documentation that the narcotic treatment physician assessed the patient to determine if an increase in the patient's dose was needed.
An interview was conducted with the medical director and confirmed that the physician did not assess the patient prior to the requested dose increases.
This is a repeat deficiency from the 5/15/2013 on-site review.
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Plan of Correction
The prescribing physician will ensure that all initial dosing notes will specify the initial dose increase and follow up and will provide specific dosages and time frames. The medical director will provide training to all NTPs to ensure that there is clarity of how all dosing adjustments should be documented. The compliance mentor and director will complete bi-weekly audits of a sampling of methadone charts for a period of 6 months and results will be reported on a monthly basis at the doctor's meeting. The agency will be in full compliance by 7/15/14. |
715.20(3) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document what materials were sent to the receiving narcotic treatment program in two of three patient records.
The findings include:
Twelve patient records were reviewed on April 22 through 24, 2014. Three of those records required documentation of information sent to the provider accepting the patient transferred. Information sent to the receiving narcotic treatment program were not documented in patient records #11 and 12.
The findings were reviewed and confirmed with the clinical director and Methadone coordinator.
This is a repeat deficiency from the 5/15/2013 on-site review.
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Plan of Correction
The Methadone Coordinator will fax discharge paperwork and last dose verification to appropriate narcotic treatment providers upon a 3B client's discharge. Medical Records will fax the requested documentation to narcotic treatment providers within 7 days of a discharged client's request. On our psychiatric unit the Nurse or Unit Clerk will fax discharge paperwork and last dose verification on all MMT patients to the appropriate narcotic treatment provider upon their discharge from the facility and document that correspondence in the patient record. The compliance mentor and director will complete bi-weekly audits on a sample of methadone charts for a period of 6 months. The results of all chart audits will be reported monthly at the chemical dependency and hospital dashboard. The agency will be in full compliance by 7/15/14. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document that it notified the referring facility of admission and the initial dose of the patient in two of three patient records.
The findings include:
Twelve patient records were reviewed on April 22 through 24, 2014. Three records were reviewed for documentation of notification to the referring facility of the admission and dosing of the referred patient. Patient records # 8 and 11 were referred by another narcotic treatment program and there was no documentation that the referring facility was notified of the admission and initial dosing of the patients.
The findings were reviewed and confirmed with the clinical director and Methadone coordinator.
This is a repeat deficiency from the 5/15/2013 on-site review.
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Plan of Correction
The Methadone Coordinator will fax our Admission Notification Document to the narcotic treatment provider that referred client to KBC for treatment after client's consent within 7 days of client's admission to KBC. On our psychiatric unit the Nurse will meet with every client who comes in already on MMT and request the patient to sign a release of information and will fax admission notifications to the appropriate NTP facility and document that correspondence in the patient record. The compliance mentor and director will complete bi-weekly audits on a sample of methadone charts for a period of 6 months. The results of all chart audits will be reported monthly at the chemical dependency and hospital dashboard. The agency will be in full compliance by 7/15/14. |
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 verification that incident reports were filed with the Department within 48 hours of the incident.
The findings include:
Administrative documentation that included the unusual incident reports was reviewed on April 22, 2014. The binder used to identify incident reports contained numerous pages of fax confirmations of documentation sent to the Department; however there was no documentation of the actual incident report.
Facility staffs were then asked to provide a copy of the incident reports for the corresponding fax confirmations.
Confirmation pages which did not include an attachment of the actual incident report were documented on: 12/20/2013; 2/28/2014; and 4/19/2014.
This was discussed with the executive director on April 24, 2014 and confirmed the facility did not have documentation of the requested unusual incident reports sent to the Department.
This is a repeat deficiency from the 5/15/2013 on-site review.
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Plan of Correction
The compliance director will create a binder where copies of all DOH incident reports along with fax confirmations will be catalogued while the originals continue to be housed with the facility director. The binder will be reviewed on a monthly basis for a period of 6 months by the compliance director and executive director to ensure that all DOH incident reports are being filed in the appropriate manner. The agency will be in full compliance by 7/1/14. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of the client records, the facility released information that exceeded the limitations imposed at 4 Pa. Code subsection 255.5(b).
The findings include:
Twelve patient records requiring consent to release information forms were reviewed on April 22-24, 2014. One of twelve client records reviewed included documentation of information released that exceeded the limitations imposed at 4 Pa. Code subsection
255.5(b), specifically patient record # 10.
Patient #10 was admitted to treatment on January 27, 2014. The record representing patient #10 contained a letter dated February 3, 2014 stating the client was in a drug and alcohol treatment program and describing the client's course in treatment; however the letter did not identify the recipient of the letter or the purpose for the release of information. Additionally, since there was no identified recipient or purpose for the release included on the letter, it was not possible to determine that a valid consent to release information had been completed.
The findings were confirmed with the facility director prior to the exit interview.
This is a repeat deficiency from the 11/22/2013 on-site review.
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Plan of Correction
The clinical team will be educated on the best way to complete a valid consent. New therapists will be educated during their training process and provided with sample consents for future reference. Clinical team will be educated on what and how information can be released once a client consents. Weekly group supervisions that are completed by clinical management will be utilized for this education. The compliance mentor and director will audit a sampling of methadone charts for a period of 6 months and results will be reported monthly at the chemical dependency and hospital dashboard meetings. The facility will be in full compliance by 7/15/14. |