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 August 6 to August 8, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Consortium 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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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of administrative documentation, the facility failed to provide at least one hour of physician time a week, on site for, every ten patients for three of the five weeks reviewed.
The findings include:
Physician time sheets for the weeks between May 13, 2013 to August 4, 2013 were reviewed August 7, 2013. The average patient census was calculated to be about 380 patients on a weekly basis.
During the week of May 20 to 26, 2013, there were 29.5 physician hours documented.
During the week of June 24 to 30, 2013, there were 30 physician hours documented.
During the week of July 1 to 7, 2013, there were 23 physician hours documented.
During the week of July 15 to 21, 2013, there were 25 physician hours documented.
During the week of July 22 to 28, 2013, there were 30 physician hours documented.
During the week of July 29 to August 4, 2013, there were 20.75 physician hours documented.
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Plan of Correction
Responsible Party(s):
The Nursing Supervisor is responsible for ensuring that the program provides at least 1 hour per week of onsite physician time for every ten patients.
Plan of Correction:
Verification of Physician Staffing schedules will be submitted to the Facility Director two weeks in advance.
Monitoring: The Medical Director, Facility Director and Nursing Supervisor will work collaboratively to monitor physician staff time to ensure that the program is providing at least 1 hour per week of onsite physician time for every ten patients at all times.
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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
Based on a review of patient records, the facility failed to ensure confidentiality in accordance with state and federal confidentiality requirements in four of six patient records reviewed.
The findings include:
Thirteen patient records were reviewed August 6-8, 2013. Six patient records were reviewed for compliance with state and federal confidentiality regulations.
Patient records # 2, 6, 11 and 13 had consents signed by the patient with "other" listed as the information being released. An informed consent is required to contain the specific information that is being released by the facility. Other is not specific.
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Plan of Correction
Responsible Party(s):
Clinical Supervisors, Intake staff, Nursing Staff and Clinical Counseling staff, are responsible for ensuring that patient files maintain confidentiality and contain valid consents to release patient information.
Plan of Correction:
The Facility Director and Clinical Supervisors will be responsible for ensuring that all staff responsible for completing releases of information, is trained on the proper completion of consents to release information by September 30, 2013.
Releases that do not meet the standard in records # 2, 6, 11 and 13 will have updated releases, that meet the requirement, completed by 09/15/2013.
Monitoring:
The Facility Director, Clinical Supervisors, and Clinical Counseling staff will review client files during bi-weekly to monthly supervision to ensure compliance with this standard.
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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 ensure at least monthly random urine drug screens for two of thirteen patient records reviewed.
The findings include:
Thirteen patient records were reviewed August 6-8, 2013. Thirteen patient records were reviewed for monthly urine drug screen results.
Patient record # 7 was missing a urine drug screen for November 2012.
Patient record # 12 was missing a urine drug screen for July 2013.
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Plan of Correction
Responsible Party(s):
The Nursing Staff has the responsibility of ensuring that all initial drug screening urinalysis for each prospective patient and random urinalysis at least monthly thereafter, are administered as required.
Plan of Correction:
The Nursing Supervisor will provide the Facility Director with a weekly report regarding the status of initial and/or monthly random urinalysis administration for each patient beginning 10/1/2013.
Monitoring:
The Nursing Supervisor, along with the Facility Director will review the status of all outstanding drug urinalysis screenings weekly. Weekly reporting will enable the Management staff to ensure that each client receives a urinalysis randomly each month, or upon admission, for all prospective patients.
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715.23(b)(14) LICENSURE Patient records
(b) Each patient file shall include the following information:
(14) Case consultation notes regarding the patient.
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Observations
Based on the review of patient records, the facility failed to complete case consultations as required in three of seven patient records reviewed.
The findings include:
Thirteen patient records were reviewed August 6-8, 2013. Seven patient records were reviewed for case consultations.
Patient # 6 was admitted December 22, 2011. The patient record had no case consultations at the time of the inspection.
Patient # 11 was admitted October 4, 2012. A case consultation is to be documented at least quarterly. There was to have been at least three case consults at the time of the inspection. The patient record had no case consultations at the time of the inspection.
Patient # 12 was admitted October 5, 2012. A case consultation is to be documented at least quarterly. There was to have been at least three case consults at the time of the inspection. There was only one case consultation in the patient record, June 7, 2013.
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Plan of Correction
Responsible:
Clinical Counseling staff is responsible for ensuring the completion of a case consultation for each quarter within the patient's first year of treatment and annually thereafter.
Plan of Correction:
The Counselor of record will document a case consultation for patient Records # 6, 11 and 12 by 9/15/2013.
Monitoring:
The Clinical Supervisor will review status of the completion of case consultation notes with their respective counselors during the supervision process at least once per month.
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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, the facility failed to ensure the psychosocial evaluations were a clinical assessment of the historical data collected in two of four patient records reviewed.
The findings include:
Thirteen patient records were reviewed August 6-8, 2013. Four patient records were reviewed for psychosocial evaluations.
Patient # 8 was admitted February 21, 2013. The psychosocial evaluation was completed March 12, 2013. However, it failed to include a clinical assessment of the collected data.
Patient # 11 was admitted October 4, 2012. An evaluation had not been completed until seven months after admission and contained a repeat of the data, patient reported commentary and no clinical assessment.
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Plan of Correction
Responsible Party(s):
Clinical Counseling Staff and Clinical Supervisors are responsible for ensuring that all patient records contain a completed psychosocial evaluation, which includes a clinical assessment of the historical data collected, within 30 days of patient admission.
Plan of Correction:
The Facility Director will be responsible for ensuring that all Counseling Staff is trained on the timeline for completion of the Psychosocial evaluation and the proper documentation of a clinical assessment of the historical data collected from the patient. This training will occur by September 15. 2013.
Records #8 and 11 will have the psychosocial evaluations updated to ensure they include a clinical assessment of the collected data.
Monitoring:
The Clinical Supervisors will provide bi-weekly to monthly supervision with staff to ensure that Psychosocial Evaluations include a clinical assessment of the collected data and are contained in the patient record as required.
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