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 February 11, 12, 13 and 14, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health Systems was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on March 17, 2008.
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Plan of Correction
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715.10(b) LICENSURE Pregnant patients
(b) A narcotic treatment program shall give pregnant patients the opportunity for prenatal care either by the narcotic treatment program or by referral to appropriate health-care providers.
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Observations
Based on the random review of 43 patient records, the facility failed to document in one out of three patient records the fact that patient #22 refused prenatal care.
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Plan of Correction
All counselors will monitor 100% of pregnant patients. This started 3/01/2008. All supervisors will assure that their assigned counselors are completing this monitoring. The counselors will assure that prenatal care is offered. This will be accomplished through treatment planning with corresponding documentation regarding the prenatal services offered through Jefferson University for our clients,including physician monitoring, proper diet and exercise. Clinical interventions with regard to how a pregnancy and a child will effect the life of the client. This is all completed with the goal of delivering a healthy baby. If the client refuses treatment, all resources should pull together to re-educate the client to try to persuade them to take advantage of the treatment planning. This planning needs to be documented and if the client refuses the treatment, this should be documented, however attempts to accept prenatal care should continue and be so documented. |
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 random review of 43 patient records and written consent to release information forms, the facility failed to maintain compliance with the regulations regarding confidentiality. Specifically, the facility failed to restrict the release of information as indicated in 4 Pa. Code 255.5 as the facility released urine drug screen results to a probation office. Additionally, a release of information signed by patient # 35 included multiple agencies on one consent form while releases of information for patients # 34, 35, and 37 did not contain all the required documentation which resulted in blank or unmarked areas of the consents. Further, the facility failed maintain confidentiality with patient take-home bottles that were returned to the facility. Specifically, returned take-home bottles were observed to be thrown into the general trash containers without first crossing out the name of the patient. This practice failed to maintain the confidentiality of the patients with take-home privileges.
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Plan of Correction
1 and 2. Re-education to the Goldman staff with regard to release of information protocols will be completed by 4/01/2008. This education will be provided by the Program Director for the supervisors and the counselors. The current release of information form will be utilized. Each location where information is to be released must be listed on the form. Each person to which information is to be released will be listed on the form. The specific information that is to be released will also be listed on the form. Each consent will have just one agency listed.
3. Names on return take home bottles- Beginning 3/01/2008, the nurses will black out the names on the bottles with a felt marker before disposing of the bottle in the trash. Education was provided by the Vice President of Nursing and the new process implemented 3/01/2008. The nursing director and infection control practitioner will be responsible for oversight of this process. |
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 random review of 43 patient records, the facility failed to ensure at least monthly random urine drug screens was completed for patients # 13, 14, 16, 18, 19, 27, 30 and 32.
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Plan of Correction
The current computer system identifies clients due for random urine drug screenings. The Administrative Assistant sets up the randomization for the urines at the beginning of each month. The counselors need to be checking the results of these urines to measure how their client is doing and to assist with treatment planning. If they do not see a urine by the 29th of the month, communication will occur to assure that a urine is completed or the results are retrieved. Supervisors will provide oversight to assure counselors are doing this as they do random documentation review each week with their counselors. This began 03/01/2008. |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on a random review of 43 patient records, the facility failed to document that the physician reviewed methadone dose levels patient # 16 at least twice a year. Specifically, the last dose review was documented on March, 2006.
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Plan of Correction
Dr. M will review each client for dosing at the time of the yearly evaluation and so document. The supervisors will assure that a notation is made in the treatment plan as to notify Dr. Mills. This notation will remain in all treatment plans until 6 months passes. This is just a back up process as our computer generates a list of clients that are due for medication review each month. This double check will be initiated by the supervisors and reviewed with the clients as weekly medical record review occurs. This will begin 04/01/2008. |
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 a random review of 43 patient records, the facility failed to document the physician's determination that the patient was responsible to have take-home medication privileges. Specifically, patient #1, 2, 3, 4, 7, 8, 9, 23, and 31 lacked the physician's documentation.
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Plan of Correction
Dr. M. will assure there is documentation on all take home clients. All clients requesting take home privileges have a request form filled out. This is our current policy. This form will now be reviewed at every annual evaluation to assure it is present,complete, and up to date. Documentation to that effect will be completed at the time of the annual review. All clients that are currently on take home medication will have their medical record reviewed by the counselors to assure there is a request form completed in their record. Education was provided to the counselors by the director on 03/01/2008. The supervisors will provide oversight. |
715.16(e) LICENSURE Take-home priveleges
(e) With an exception granted under subsection (d), a narcotic treatment program may not permit a patient to receive more than a 2-week take-home supply of medication.
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Observations
Based on a random review of patient records, the facility failed to obtain an exception from the Department before it provided patient # 10 with fifteen take-home doses.
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Plan of Correction
Corrective Plan: All requests for exceptions will be completed prior to any take home doses being dispensed. This is our current policy. Re-education was provided to all nurses,counselors and supervisors by the director as to the content of this policy. This was completed on 03/01/2008. There will be no doses dispensed by the nurses without reviewing a copy of the exception. All take home doses requiring an exception will be monitored by the dispensing nurse along with appropriate exception documention. The Program Director will oversee the plan to assure compliance. |
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 random review of 43 patient records, in one of one patient record the physician ordered a split methadone dose for patient # 20 effective July 19, 2007. The medication record documents that patient # 20 was placed on a split dose effective June 28, 2007. There were no stop orders issued by the physician between June 28, 2007 and July 19, 2007.
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Plan of Correction
Every medication order shall be signed by the physician. This order is then placed in to the computer by the nurse. All orders will be reviewed by the nurse prior to placing the order in to the computer. No medication will be dispensed by the nurse without a corresponding written order. If there is no written order, the medication information will not be entered in to the computer by the nurse and the nurse will clarify the situation with the physician. This is the current policy. Re-education of this policy was reviewed with all nurses by the VP of Behavioral Health on 03/06/2008. The Program director will be responsible for assuring monitoring of this process is complete to assure compliance. |
715.17(c)(3)(i-v) 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:
(3) Inspection of storage areas. A narcotic treatment program shall inspect all drug storage areas and the dispensing station at least quarterly to ensure that the areas are maintained in compliance with Federal, State and local laws and regulations. A narcotic treatment program shall develop and implement written policies and procedures regarding who performs the inspections, how often, and in what manner the inspections are to be documented. The policies and procedures shall include the following:
(i) Disinfectants and drugs for external use shall be stored separately from oral and injectable drugs.
(ii) Drugs requiring special conditions for storage to insure stability shall be properly stored.
(iii) Outdated and contaminated drugs shall be removed and destroyed according to Federal and State regulations.
(iv) Administration of controlled substances shall be documented.
(v) Controlled substances and other abusable drugs shall be stored in accordance with Federal and State regulations.
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Observations
Based on observation and staff interviews, the facility is not conducting inspections of the medication storage area. The facility had a policy and procedure that required inspections at least quarterly.
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Plan of Correction
The institutional policy had all areas of medication storage inspected. This area was included in the hospital policy. This area was not being inspected. Annual review of Pharmacy policies did not identify this as an area which should be changed. The Director of the Pharmacy changed the policy to reflect that Goldman will not be inspected as a medication storage area of the hospital, however the Goldman dispensing area will still be inspected quarterly as a part of the environmental rounds process. This is completed by the Infection Control Practitioner and so documented with findings being reported to the Infection Control Committee. This process started 03/01/2008. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
The facility failed to provide patients # 29 and 40 with the required minimum of 2.5 hours of psychotherapy each month, specifically patient # 29 had no documented hours of therapy for the month of November, one hour of psychotherapy documented for December and four hours documented for January and patient # 40 had no recorded hours for September, October, and December; one hour of psychotherapy was documented for November and during the month of January there were four documented hours of psychotherapy services.
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Plan of Correction
The counselors will assure that each client receives the minimum therapy hours according to standard 715.19(1). This will be based on the documented treatment plan goals and the assessment of attaining those goals. The counselors will do assessments at the time of therapy sessions and any other time deemed necessary by a change in the client's condition that would require added therapy hours. The minimum hours will be calucated and tracked by the counselors. The supervisors will provide oversight of this process as they review the client's progress with the counselors at their weekly meetings. Lists of clients due for therapy will be provided by the counselors to the registration clerk. The clerk will notify the client that he or she is due for a session and see their counselor prior to leaving the building. This will begin 04/15/2008 and be completed by 5/15/2008. |
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a random review of records, the facility failed to provide the required patient specific information for patients # 26, 34 and 35 to the receiving narcotic treatment facility.
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Plan of Correction
All documents required for transfer by standard 715.20(1) will be listed on the front of the cover sheet which will be included in the fax. This will ensure all documents are present. The fax confirmation will be kept in the record as proof of what was sent. The Administrative Assistant of the clinic has created the list for the fax cover sheet. The supervisors will assure that there is a supply of these fax sheets available when a transfer occurs. This procedure was reviewed with the counseling staff by the supervisors on 03/10/2008 and the process is to begin immediately. Supervisors will provide oversight of this procedure. This is a re-education of our current procedure. The addition of the cover sheet is an extra added check to assure all appropriate paper work is present. |
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
The facility failed to restrict the policy and procedure on patient termination to the reasons addressed in the regulations. The facility permitted excessive absence, urine testing which indicated illicit drug usage, and failure to seek employment as reasons to terminate the patient from treatment.
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Plan of Correction
The policy on patient termination will be restricted to the content of regulation 715.21(1)i-iv. Education was provided to all staff regarding this on 02/25/2008 by the program director. The Administrative Assistant made the changes in the policy. All termination will require a team discussion and the reason for termination will be reviewed for regulation compliance at that time. This process began on 2/26/2008. |
715.21(2) 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.
(2) A patient terminated involuntarily, except a patient who commits or threatens to commit acts of physical violence, shall be afforded the opportunity to receive detoxification of at least 7 days. The detoxification may take place at the facility or the patient may be referred to another narcotic treatment program or hospital licensed and approved by the Department for detoxification.
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Observations
Based on a random review of 43 patient records, the facility failed to follow their policy and procedure regarding patient terminations, specifically failing to provide patients # 34 and 35 with written notification of termination. Additionally, the record of patient #32 contained written notification of termination but it was not signed by patient and written on patient signature line was the statement that the signature was not needed; a signature was required on the document as it indicated the patient had received notification of termination and that the patient was advised of the appeal rights.
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Plan of Correction
Our current policy states that all clients will receive written notification of termination. They will be required to sign. A copy of the notification will be maintained for the record. Our current process was re-reviewed with the counseling staff and supervisors on 02/25/2008 by the program director. The supervisors will provide oversight to assure compliance. All terminations will be reviewed for discussion and monitoring of this issue will occur at that time as a double check. This will begin immediately. |
715.22(b) LICENSURE Patient grievance procedures
(b) The procedure shall permit aggrieved patients a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director. If the grievance is filed against the narcotic treatment program director, the review of the case shall be conducted by either a multi-representative group of the narcotic treatment program or a subcommittee of the governing body instituted for the express purposes of grievance adjudication.
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Observations
Following a review of the facility's policy and procedure and the documented patient grievances, the facility failed to follow procedure to address grievances and document responses. In response to licensing specialist questions, the grievances were updated during the monitoring visit to document the resolutions.
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Plan of Correction
The Program Director will review all grievances with each supervisor to assure all grievances are addressed and responses documented. Education was provided to the supervisors by the Program Director on 2/25/2008. The education addressed these issues. The Program Director will be involved with all grievances to assure each is addressed and responses so documented. |
715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
Based on the random review of 43 patient records, the facility failed to obtain the required Mantoux test for tuberculosis for patients # 18 and 21. The Mantoux test for patient # 10 was not completed within the 14 day requirement.
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Plan of Correction
There is an existing protocol to ensure that all clients receive their required Mantoux test. Re-education was conducted by the program director for all clinic staff regarding the need to comply within the 14 day requirement. This education was completed on 2/25/2008. The counselors will provide oversight that their assigned clients needing their Mantoux test is completed within the 14 day window. |
715.23(b)(11) LICENSURE Patient records
(b) Each patient file shall include the following information:
(11) Counselor notes regarding patient progress and status.
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Observations
Based on random review of 43 patient records, the facility failed to provide individualized progress notes that were consistent with the patient's treatment plan. Patient records # 2, 30 and 31 contained progress notes that were disjointed, the "Data" component of the note did not correspond with the "assessment" and "plan" of the documentation. Additionally, patient # 4 record had no progress notes since December 2007. Patient # 9 progress notes had the same "assessment" and "plan" since October 2007.
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Plan of Correction
Data,assessment and plan (DAP note) training was conducted for all staff during the last week of February, 2008. There is another session scheduled for March 25, 2008. This education is provided by the education department. Supervisors will provide oversight to assure all counselors are utilizing this format and to assure the notes are relevant to the issues of the client. |
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 random review of 16 closed patient records, the facility failed to document discharge information for patients # 6, 8, 17, 24, 26, 27, 34, 35 and 39 that included reasons for entering treatment, treatment objectives and progress and status at discharge.
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Plan of Correction
The discharge form has been revised to include reasons for entering tretment, treatment objectives and progress toward and status of treatment at discharge. An educational meeting was held to review this revisions on 03/03/2008. All staff were educated by the program director. Clinical supervisors will provide oversight to assure the new form replaces the old, along with oversight to assure compliance. This will be accomplished by weekly chart review between supervisors and clients as each discharge is monitored. This implementation will be completed by May 1, 2008. |
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 random review of 43 patient records, the facility failed to ensure that all annual evaluations were completed as required. Patient records # 4, 21 and 29 did not contain evaluations that were due in 2007.
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Plan of Correction
The timing of all annual evaluations will now take place on the anniversary date that the client began treatment. The Administrative Assistant will provide information from the computer as to all anniversary dates for all clients. This list will be provided to the clinical supervisors. The supervisors will review the list and the expectation with all the counselors. Education was provided to counselors by the supervisors on 3/3/08. Supervisors will assure compliance with this process. This process will begin 04/01/2008. |
715.23(d) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
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Observations
Based on a review of 43 randomly selected patient records, the treatment plans contained global and non-specific goals; the contents did not address patient specific needs and goals, specifically, patient records # 1,2, 3, 4, 9, 10, 13, 14, 15, 16, 18, 35, 36 and 40.
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Plan of Correction
The current policy and protocol for completing treatment plans was reviewed with all staff by the program director on 2/25/2008. Re-education and expectations were completed. The supervisors will provide oversight to ensure the counselors treatment plans are relevant. This will be done during weekly monitoring of treatment plans during supervisory sessions between counselors and their supervisors. |
715.23(d)(1) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(1) The treatment plan shall identify the behavioral tasks a patient shall perform to complete each short-term goal.
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Observations
The facility failed to develop treatment plans that contained short term goals with measurable steps. Further, the treatment plans failed to identify support systems needed by the patient. Of the the 43 patient records reviewed, patient records # 3, 4, 6, 9, 10, 13, 14, 15, 16, 18, 19, 32, 36 and 40 not contain measurable tasks to be completed by the patient to accomplish the short term goals.
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Plan of Correction
Dr. Glass will conduct an educational program for the supervisors and the counselors addressing treatment planning. This will be conducted on 4/14/2008. The education will address documentation of conversation with clients as they mutually identify and agree upon support systems. The education will also target how to identify and document behavioral tasks that the clients can utilize which will help them reach their treatment goals. These tasks will be measurable and realistic. Counselor treatment plans will be reviewed for the presence of this documentation during weekly meetings with their respective supervisors. |
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 review of administrative documentation provided during the inspection and staff interviews, the facility failed to submit documentation of unusual incidents to the Department as required.
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Plan of Correction
The Program Director will post the list of 5 unusual incidents that must be reported to the Department within 48 hours. The Program Director provided education to the supervisors and counselors on 02/25/2008 reviewing the list and the fact that the unusual incident must be so documented and reviewed immediately with their supervisor. The supervisors will review these incidents with the Director before they are sent to the Department. The supervisors will provide oversight to the counselors to assure compliance and the Program Director will review all incidents prior to sending them to the State. |