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 9-12, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Parkside Recovery 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 September 9, 2010.
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Plan of Correction
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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 maintain the confidentiality of all patient records in accordance with state and federal confidentiality requirements in three of six patient records.
The findings include:
Thirty patient records were reviewed August 9-12, 2010. Six patient records were reviewed specifically for consents to release information.
Patient records # 1 and 9 contained blank consents to release information forms, but they were signed.
Patient record # 3 contained a consent to release information form without identifying to whom the disclosure was to be made.
Patient record # 9 contained a consent to release the patient's urine drug screen results to the probation officer, exceeding 4 Pa Code 255.5.
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Plan of Correction
There will be a training with counselors regarding the appropriate way to fill out a release of information. The training will include instructions on completely filling out the release including the disclosure to who the release of information will be going. Training with intake and counselors will stress that no release will be signed by a client without being fully filled out. The training will also include educating counselors on the requirements of 4 PA Code 255.5. Charts will be audited to remove any consent to release information to probation/parole officer regarding a clients UDS screen.
Charts will be monitored by the clinical supervisors to assure that this deficiency does not repeat. Training will be completed before the end of September 2010
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715.21(1)(i-iv) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
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Observations
Based on the review of administrative documentation, the facility failed to restrict the reasons for involuntary termination to those reasons allowed by regulation.
The findings include:
The policy and procedure manual and the patient handbook were reviewed for the facility procedure on involuntary terminations. The patient handbook contains statements that the patient can be involuntarily terminated for excessive absence and "misuse" of methadone.
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Plan of Correction
The terms excess absenteeism and misuse of methadone" will be removed from the client handbook immediately. Thus the policy and client handbook will read the same.
Done Immediately
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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 and administrative documentation, the facility failed to ensure the psychosocial evaluations were a clinical assessment of the historical data collected in six of seven patient records.
The findings include:
Thirty patient records were reviewed on August 9-12, 2010. Seven patient records were reviewed for psychosocial evaluations.
Patient records # 1, 2, 3, 8, 10 and 27 had psychosocial documents that contained a repeat of the data, patient reported commentary and no clinical assessment of the historical data collection.
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Plan of Correction
There will be clinical training for counselors regarding how to properly do a clinical assessment based on the client's historical information
Supervisors will monitor/evaluate each psychosocial assessment before it is signed to assure compliance this deficiency does not re-occur.
Training will be on September 27th 2010
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715.23(b)(22) LICENSURE Patient records
(b) Each patient file shall include the following information:
(22) Aftercare plan, if applicable.
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Observations
Based on a review of patient records and administrative documentation, the facility failed to document an aftercare plan in two of two patient records.
The findings include:
Thirty patient records were reviewed on August 9-12, 2010. Two patient records required an aftercare plan. Patient records # 20 and 26 did not contain documentation of an aftercare plan.
Patient record # 20 was discharged as having completed treatment on January 22, 2010. There was no documentation of an aftercare plan in the patient record.
Patient record #26 was discharged as having completed treatment on March 3, 2010. There was no documentation of an aftercare plan in the patient record.
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Plan of Correction
There will be a clinical training to educate counselors the requirement of documenting an aftercare plan for every client discharged. A aftercare plan will be attached to every discharge packet to assure the compliance with POC.
Supervisors will be responsible for monitoring each discharge packet during supervision to assure that a aftercare plan is completed to assure this deficiency does not happen again
Training to be held: September 27, 2010
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715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on a review of patient records and administrative documentation, the facility failed to document all of the required information in discharged patient records.
The findings include:
Thirty patient records were reviewed August 9-12, 2010. Fourteen patient records were reviewed for complete discharge summaries. Eleven of fourteen patient records did not document all required information in the discharge summaries.
Patient records # 18, 19, 20, 21 22, 24, 25 and 26 did not document the reasons for treatment.
Patient records # 17, 18, 20, 21, 25, and 26 did not document the response to treatment.
Patient records #16, 20, 24 and 26 did not document the services offered.
Patient records #20, 24, 25, and 27 did not document the client's status at discharge.
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Plan of Correction
A clinical training will be held to re-educate the counselors on how to fill out a discharge summaries and what information the summary must contain including client's response to treatment, services offered the client and the client's status at discharge.
Supervisors will be responsible for monitoring/auditing all discharge packets to assure completeness of the discharge summary. This will be done during supervision on a weekly basis. Supervisor will not sign off on any discharge packet that is not fully completed to assure full compliance with the POC.
Time: Training will be held September 27th, 2010
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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 and administrative documentation, the facility failed to document the attempt or completion of patient follow-up contact in four of eight patient records reviewed.
The findings include:
Thirty patient records were reviewed on August 9-12, 2010. Eight patient records were reviewed for follow-up documentation. Patient records # 17, 26, 27, and 28 did not document follow-up attempts in accordance with the facility policy and procedure.
Patient records #17 and 26 did not have documentation of a follow-up attempt.
In addition, the facility policy states that a follow up questionnaire will be sent out thirty days after discharge. In patient records #27 and 28 the patient follow-up letter was sent out one day after the patient was discharged.
Patient # 27 was discharged on May 5, 2010. The patient follow-up letter was sent out on May 6, 2010.
Patient # 28 was discharged on June 3, 2010. The patient follow-up letter was sent out on June 4, 2010.
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Plan of Correction
The Program Director will meet with all clinical supervisors to educate them regarding the timeliness and completeness of all follow up letters to discharged consumers. All follow up letters sent will be documented on a spreadsheet and monitored /auditing by the clinical supervisors to assure this deficiency is adequately addressed and will not re-occur.
Meeting will be held September 13, 2010
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on the review of patient records and administrative documentation, the facility failed to complete annual evaluations in accordance with the regulations in two of six patient records reviewed.
The findings include:
Thirty patient records were reviewed August 9 through 12, 2010. Six patient records required documentation of an annual clinical review. Two of six patient records did not contain documentation of an annual clinical evaluation. Patient records # 26, and 30 did not contain documentation of annual clinical evaluations.
Patient #26 was admitted on February 13, 2006. The last clinical annual evaluation was completed on February 16, 2009.
Patient #30 was admitted June 6, 1984 the last clinical annual evaluation was completed on June 23, 2009.
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Plan of Correction
A training will be held to educate the counselors on the requirement of filling out an annual evaluation timely and appropriately. The annual evaluation will be attached to the annual physical form so both the Dr. and counselor will do them at the same time. The supervisor will receive and assess each annual evaluation before signing off on them.
Supervisors will monitor this process on their spreadsheet and will go over each during supervision to assure that this deficiency will not happen again.
Training: September 27th.
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