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 3-5, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Narcotic Addict Rehabilitation Program of Thomas Jefferson University 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)(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 the review of patient records, the facility failed to document in the patient record the basis for determination of current dependency in patient record # 1.
The findings include:
Patient # 1 was admitted January 31, 2012. The patient was referred to the narcotic treatment program on January 18, 2012 after being detoxified for opiates at another facility. The patient submitted three pre-admission urine drug screens prior to admission. The January 19, 2012 urine drug screen was negative for opiates; January 25, 2012 was positive for opiates and the January 30, 2012 was negative for all substances including opiates. The patient received an admission history and physical on January 31, 2012. Current dependency was not documented. There was no documentation of the physician's justification for admitting the patient without current dependency.
A discussion with facility medical staff confirmed the finding.
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Plan of Correction
The Division Director has reviewed with medical personnel the mechanisms for adequately documenting opiate dependency at the time of admission. Chart review to be conducted by the Clinical Supervisor will be conducted to ensure that medical personnel only admit individuals with documented opiate dependence. |
715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
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Observations
Based on the review of patient record documentation, the facility failed to ensure the physician documented the rationale for granting take home medication in two of two patient records.
The findings include:
Sixteen patient records were reviewed April 3-5, 2012. Two records were reviewed for documentation pertaining to take home medication.
Patient # 5 was admitted June 7, 2011. Documentation in the patient record revealed patient # 5 was granted one take home bottle but there was no rationale for this determination documented by the physician.
Patient # 7 was admitted February 7, 2003. The patient was granted take home privileges October 21, 2011. There was no rationale documented by the physician for granting the take home privilege.
This is a repeat deficiency from the March 2011 monitoring.
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Plan of Correction
The Division Director has reviewed with medical personnel the need to document the rationale for granting take home medications on the program-specific form. The Clinical Supervisor will review take-home request forms to ensure that approporiate documentation is provided by medical personnel granting take home privileges. |
715.16(b)(1-8) LICENSURE Take-home privileges
(b) The narcotic treatment physician shall consider the following in determining whether, in exercising reasonable clinical judgment, a patient is responsible in handling narcotic drugs:
(1) Absence of recent abuse of drugs (narcotic or non-narcotic), including alcohol.
(2) Regular narcotic treatment program attendance.
(3) Absence of serious behavioral problems at the narcotic treatment program.
(4) Absence of known recent criminal activity.
(5) Stability of the patient 's home environment and social relationships.
(6) Length of time in comprehensive maintenance treatment.
(7) Assurance that take-home medication can be safely stored within the patient 's home.
(8) Whether the rehabilitative benefit to the patient derived from decreasing the frequency of attendance outweighs the potential risks of drug diversion.
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Observations
Based on the review of patient records and discussion with staff, it was determined the facility failed to ensure that the eight point criteria was met before granting take home privileges in one of three patient records.
The findings include:
Sixteen patient records were reviewed April 3-5, 2012. Three patient records were reviewed for take home privilege information.
Documentation in patient record # 5 revealed the patient was receiving take home privileges but was was failing to meet her established counseling appointments. In addition, documentation in the record indicated there were concerns regarding patient # 5's living environment.
Discussion with staff confirmed the findings.
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Plan of Correction
The Program Coordinator re-emphasized with clinical and medical personnel the criteria that need to be met before take home privileges can be granted. Furthermore, in addition to this review of criteria, we have implemented a required group presentation/review of all requests for take home privileges. Review of clinical records of individuals granted take home privilege, to be conducted by the Senior Therapist/program Coordinator, is anticipated to ensure 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 verbal orders were signed within 24 hours as required.
The findings include:
Patient # 8 was admitted April 14, 2011. A verbal order was issued on April 23, 2011. It was not signed by the issuing physician.
Patient # 10 was admitted November 29, 2011. A verbal order was issued on January 3, 2012. It was signed January 5, 2012 by a physician other than the issuing physician.
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Plan of Correction
The Division Director has reviewed with medical personnel the requirements surrounding signing of verbal orders. For a period of three months, the Head Nurse will review verbal orders to ensure that they are being signed as required. |
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 a clinical assessment of the historical data collected or completed within the policy-stated 30 days of admission.
The findings include:
Sixteen patient records were reviewed April 3-5, 2012. Five patient records were reviewed for psychosocial evaluations.
Patient # 1 was admitted January 31, 2012. An evaluation had not been completed at the time of the monitoring inspection.
Patient # 2 was admitted September 16, 2011 and had a psychosocial evaluation that contained a repeat of the data, patient reported commentary and no clinical assessment.
Patient # 3 was admitted October 11, 2011 and had a psychosocial evaluation that contained a repeat of the data, patient reported commentary and no clinical assessment.
Patient # 8 was admitted April 14, 2011 and had a psychosocial evaluation that contained a repeat of the data, patient reported commentary and no clinical assessment.
Patient # 10 was admitted November 29, 2011 and had a psychosocial evaluation that contained a repeat of the data, patient reported commentary and no clinical assessment.
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Plan of Correction
The Division Director and Division Coordinator of Treatment and Training have reviewed this finding with staff. This training/review emphasized the need for psychosocial evaluations to be more than recapitulations of acquired information. Psychosocial evaluations will routinely be reviewed by the acting supervisor to ensure that they are evaluative and not simply a repeat of the data. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on the review of patient records, the facility failed to document the attempt or completion of patient follow up contact in two of three patient records reviewed.
The findings include:
Sixteen patient records were reviewed April 3-5, 2012. Three patient records required documentation of an attempt or completion of a follow up contact. The facility's policy and procedure is to initiate this attempt 60 days post discharge.
Patient # 10 was admitted November 29, 2011. The patient was discharged January 11, 2012. The follow up was to have been initiated by March 10, 2012. There was no documentation of the follow-up attempt.
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Patient # 14 was admitted February 19, 2010. The patient was discharged as completing treatment November 7, 2011. The follow up was to have been initiated by January 5, 2012. There was no documentation of the follow-up attempt.
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Plan of Correction
Clinical staff attempting follow-up interviews are being made aware of the importance of documenting FU efforts by the Division's Coordinator of Training. Successfully completed follow-up interviews are made a part of the clinical record by the counselor conducting the interview. Unsuccessful efforts will now also be documented in the record as indicated by a sign-off recording that efforts at post-treatment contact failed. The Senior Therapist will be responsible for monitoring successful completion of this task. |