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 July 26 through July 29, 2010 by staff from the Division of Drug and Alcohol Program Licensure. 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 and a plan of correction is due on August 25, 2010.
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Plan of Correction
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715.9(a)(1) 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:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on the review of patient records and the facility's policy and procedure, as well as interviews with the project director and facility director, the facility failed to verify that the individual has reached 18 years of age in seventeen of twenty-five records.
The findings include:
Twenty-five patient records were reviewed July 26 through July 29, 2010 . Twenty-five patient records were reviewed for documentation that the patient had reached 18 years of age. Patient records # 1, 2, 5, 7, 10, 11, 12, 13, 14, 15, 16, 17, 18, 22, 23, 24, and 25, did not contain documentation that the patient had reached 18 years of age.
According to the facility policy and procedure. "It is the policy of Kirkbride Center staff to obtain clear, unalterable means of identification on all patients entering the facility which will include a photograph, patient's name and date of birth." The review of patient records revealed that the facility failed to maintain the documentation in accordance with policy.
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Plan of Correction
1. The Admissions Department will be trained in the requirement that the facility must certify that each patient is at least 18 years of age or older prior to the administration of a narcotic agent.
2. The Project Director and the Admissions Supervisor will develop a checklist of elements necessary to ensure that each patient is at least 18 years old. |
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 and the facility's policy and procedure, as well as interviews with the project director and facility director, the facility failed to verify the identity of the patient prior to the administration of an agent in seventeen of twenty-five records reviewed.
The findings include:
Twenty-five patient records were reviewed on July 26 through July 29, 2010. Twenty-five patient records were reviewed for patient identity information. Patient records # 1, 2, 5, 7, 10, 11, 12, 13, 14, 15, 16, 17, 18, 22, 23, 24, and 25 did not contain documentation of the patient's name or date of birth.
According to the facility policy and procedure, "It is the policy of Kirkbride Center staff to provide or obtain clear unalterable means of identification on all patients entering the facility, which will include a photograph, patient's name, and date of birth. The review of patient records revealed that the facility failed to maintain the documentation in accordance with policy.
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Plan of Correction
1. The Admissions Department will be trained in the requirement that the facility must certify the identity of each patient prior to the administration of a narcotic agent.
2. The Project Director and the Admissions Supervisor will develop a checklist of elements necessary to verify the identity of each patient.
3. Once completed, the facility will seek technical assistance from the Pennsylvania Department of Health, Division of Drug and Alcohol Program Licensure to ensure compliance with the state standard. |
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 a review of patient records and an interview with the project director and the facility director, the facility failed to ensure that the patient was initially dosed following the completion of a drug screen urinalysis in two of twenty-five patient records. In addition, rapid drug testing was used in six of twenty-five patient records.
The findings include:
Twenty-five patient records were reviewed on July 26 through July 29, 2010. Twenty-five patient records were reviewed for drug screen urinalysis prior to a patient's initial dose. Per regulation, a narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter. The facility failed to document the completion of a drug screen urinalysis prior to dosing in patient records #7 and 11.
Patient #7 was admitted to treatment on July 20, 2010. Patient #7 received a dose of 30 mg on July 20, 2010, the same date that the patient had submitted a urine specimen for a drug screen urinalysis.
Patient #11 was admitted to treatment on June 25, 2010. Patient #7 received a dose of 30 mg on June 25, 2010 the same date that the patient had submitted a urine specimen for a drug screen urinalysis.
In addition, the narcotic treatment program used an instant urine drug screen test in patient records # 1, 2, 3, 10, 17 and 25. This is not a completed drug-screening urinalysis in that the laboratory performing the testing is not CLIA approved.
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Plan of Correction
1. In the absence of a lab-generated urinalysis result, the facility's Narcotic Treatment Physicians document the following the indicate physiologic affiction to heroin or other opiate:
A. Patient statement to physician.
B. Early signs of withdrawal such
as pupilary dilation,
lacrimation, rhinnorhea,
piloerections, yawning
C. Signs of fresh track marks
and/or abscesses, in addition
to the above indicators.
2. In the absence of a lab-generated urinalysis result, the facility's Narcotic Treatment Physicians document the following indicators to determine that a patient has been addicted to heroin or other opiates for a period of at least one year prior to the date of intake:
A. Patient statement to physician.
B. Documented history of one-year
addiction on file (for example,
through a Medical Record from a
previous admission to either
detox or rehab.
C. Previous history on file
indicating Methadone
administration.
D. Verifiable history from family
or friends.
E. Other history as noted.
3. The Narcotic Treatment Physicians, who meet weekly, will be retrained by the Medical Director in the requirements of documenting physiologic dependence to opiates as well as at least a one-year addiction to heroin or other opiates. |
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 an interview with the project director and facility director, the narcotic treatment program failed to document the consultation between the narcotic treatment physician determining the initial dose and the narcotic treatment physician and/or the physician extender performing the physical examination in five of twenty-three records.
The findings include:
Twenty-five patient records were reviewed on July 26 through July 29, 2010. Twenty-three patient records were required to document a consult between the narcotic treatment physician determining the initial dose and the narcotic treatment physician and/or the physician extender performing the physical examination in five of twenty-three records.
Record #3-Patient was admitted on 7/20/10. The CRNP completed the physical examination on 7/20/10. The narcotic treatment physician determined the initial dose on 7/20/10, but did not document the consultation with the CRNP who completed the physical examination.
Record #6-Patient was admitted on 12/23/09. The PA completed the physical examination on 12/24/09 The narcotic treatment physician determined the initial dose on 12/24/09, but did not document the consultation with the PA who completed the physical examination.
Record #7-Patient was admitted on 7/20/10. The CRNP completed the physical examination on 7/20/10 The narcotic treatment physician determined the initial dose on 7/20/10, but did not document the consultation with the CRNP who completed the physical examination.
Record #9-Patient was admitted on 6/17/10. The CRNP completed the physical examination on 6/17/10 The narcotic treatment physician determined the initial dose on 6/18/10, but did not document the consultation with the CRNP who completed the physical examination.
Record #10-Patient was admitted on 12/9/09. The narcotic treatment physician completed the physical examination on 12/9/09 The narcotic treatment physician determined the initial dose on 12/9/09, but did not document the consultation with the narcotic treatment physician who completed the physical examination.
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Plan of Correction
1. To ensure compliance with the requirement that consultation occurs between the Narcotic Treatment Physician and the Licensed Independent Practitioner performing the phyician when the two are different people, the facility will develop a consultation form.
2. The consultation form will be used to ensure compliance with the standard.
3. The Narcotic Treatment Physicians, who meet weekly, will be trained in the documentation of consultation by the Medical Director. |
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 a review of patient records, and an interview with the project director and facility director, the narcotic treatment program failed to restrict the determination of a patient's dose to the physician in twenty-five of twenty-five patient records.
The findings include:
Twenty-five records were reviewed on July 26 through July 29, 2010; all twenty-five records were reviewed for medication orders. Patient records #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15,16,17,18,19, 20, 21, 22, 23, 24, and 25 contained dosing orders that ordered changes in medication that included standing orders that took place without ongoing physician review.
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Plan of Correction
1. The Medical Director has met with the Medical Staff, which includes both Narcotic Treatment Physicians as well as Licensed Independent Practitioners, to review the ordering of changes in medications.
2. The Medical Staff will write tapers and titrations for no more than three days. The patient's response to the taper or titration will be assessed prior to continuing the taper or titration for an additional period of no more than three days.
3. The Clinical Director will conduct a four-month performance improvement project to ensure compliance with the new policy. Results will be reported monthly the Executive Committee, internally called Dashboard,for oversight and monitoring. |
715.23(b)(12) LICENSURE Patient records
(b) Each patient file shall include the following information:
(12) Applicable consent forms.
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Observations
Based on the review of client records, and an interview with the project director and facility director, the facility failed to document informed and voluntary consent forms for the patient for the disclosure of information contained in fourteen of twenty-four patient records.
The findings include:
Twenty-five patient records were reviewed on July 26, 2010 through July 29, 2010. Twenty-four patient records records required documentation of informed and voluntary consent. The facility did not document complete informed and voluntary consents for the release of information in patient records #5, 9, 11, 12, 13, 15, 16, 17, 18, 19, 20, 21, 23, 24.
Patient records #5, 12, 13, 18, and 19 did not document the purpose of the disclosure on the consent to release information form.
Patient record #18 checked "other" information to be released but did not document what the "other" information was to be released.
Patient record # 11, 13, and 16 did not document what was being released on the consent to release information form.
Patient records # 9, 11, 12 13, 15, 16, 18, and 19 did not document if the patient was offered a copy of the consent to release information form.
Patient records # 12, 18, and 19 the witness did not date their signature on the consent to release information form
Patient records # 15,17, 20, 21, 23, and 24 did not give the patient the option to verbally revoke the consent to release information form.
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Plan of Correction
1. The Admission Department will undergo a staff training in the appropriate complete of consents.
2. Following the training, the Admissions Supervisor will initiate a performance improvement project designed to ensure compliance with the standard.
3. The performance improvement project will be executed through a review of consent in randomly selected records each month during a four-month period. In the performance improvement project, the sample size will be 10 percent of the total number of admissions to 3B level of care during the month.
4. Results will be reported monthly to the Chemical Dependency Executive Committee, internally called Dashboard, for a period of four months to ensure compliance. |
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 a review of patient records and an interview with the project director and facility director the facility failed to document psychosocial evaluations that included all required components in twenty-one of twenty-five patient records.
The findings include:
Twenty-five patient records were reviewed on July 26 through July 29, 2010. Twenty-five patient records were reviewed for psychosocial evaluations.
In patient records # 1,2,5,6,8,10, 11,12,13,14,15,16,17,18,19,20,21,22,23,24, and 25 counselor's did not evaluate the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment or include the counselors conclusion/impressions of the patient. The psychosocial evaluations did not document evaluative information but rather listed or restated information gathered in the histories.
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Plan of Correction
1. The Clinical Director will initiate a performance improvement project designed to improve the quality of psychosocial evaluations, to ensure that the evaluations are not a recitation of previously stated facts and to meet the state's requirements that the evaluations include the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors that might inhibit treatment and the counselor's conclusions/impressions.
2. The performance improvement project will evaluate randomly selected records for a period of four months. The size of the sample will be 10 percent of the total number of admissions during each month of the four-month period.
3. Results will be shared with primary therapists and will be reported monthly to the Chemical Dependency Executive Committee, internally called Dashboard, for oversight and monitoring. |