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 September 19-21, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Aldie Counseling 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.
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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, specifically the narcotic treatment physician, failed to document in the patient's record the evidence of a one year history of addiction in three of four patient records.
The findings include:
Nineteen patient records were reviewed from September 19-21, 2011. Four patient records were reviewed specifically for documentation of the basis for the determination of current dependency and evidence of a one year history of addiction. Three patient records failed to include documentation of evidence by the physician of a one year history of addiction.
Patient records # 7, 8 and 11 had patient statement listed as the determination of one year history of addiction.
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Plan of Correction
The form utilized by the program physicians for the initial physical examination and medical history was revised to indicate that the patient's statement to the physician cannot be used as the only indicator of at least a one year history of narcotic addiction. The NTP policy and procedure manual section 715.9 Intake was also revised to note this requirement. The program coordinator has informed the program physicians of this form change and requirement, and will review the physician completed forms to insure that this requirement is being followed. |
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 the review of patient records, the facility failed to maintain the confidentiality of all patient records in accordance with 42 CFR Part 2, Subpart B, subsection 2.22 and 28 Pa. Code 709.28.
The findings include:
Nineteen patient records were reviewed September 19-21, 2011. Nine records were reviewed specifically for documentation of consents to release information. Two patient records contained consents to release information that were signed by the patient and the witness prior to the completion of the consent to release.
Patient record # 8 contained three signed blank consents to release information.
Patient record # 18 contained two signed blank consents to release information.
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Plan of Correction
Notification was sent to all staff members by the operations/facility director that "All sections of the Consent/Authorization to Release Information form are to be completed before the client and staff member signs the document." The requirement was also stipulated at the Oct. 4 staff meeting and in the minutes of the meeting sent to all staff. Program coordinators will monitor compliance through their regular clinical chart reviews. |
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 the physician dated the signature after submitting a verbal order in four of four patient records.
The findings include:
Nineteen patient records were reviewed September 19-21, 2011. Four records contained documentation of a physician's verbal orders. While the physician did sign these verbal orders, the signature was not dated. Therefore, there was no way to determine whether the verbal order was signed within 24 hours as required by regulation.
Patient # 13 had documentation of a verbal order to increase the patient's dose on May 28, 2011. The physician signed the verbal order, but failed to date his signature.
Patient # 14 had documentation of verbal orders to change the patient's dose or schedule on four different dates, March 11, 2011, July 26, 2011, August 20 and August 29, 2011. The physician signed the four verbal orders, but failed to date his signature.
Patient # 17 had documentation of a telephone verbal order on March 16, 2011. The physician signed the verbal order, but failed to date his signature.
Patient # 18 had documentation of a telephone verbal order on March 16, 2011. The physician signed the verbal order, but failed to date his signature.
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Plan of Correction
The Verbal Medication Orders policy was revised to further stipulate and clarify the procedure for providing the program physician with a copy of the verbal order, as received and recorded by the program nurse, which is then to be verified, signed and dated by the physician within 24 hours of having given the verbal order. The program coordinator reviewed this procedure with the physician and nursing staff, and shall monitor compliance of the physician including the date when the verbal order verification was signed through regular clinical chart reviews. |
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 the review of patient records and a discussion with administrative staff, the facility failed to demonstrate the physician made the determination of the patient's dose in three of nineteen patient records.
The findings include:
Nineteen patient records were reviewed on September 19-21, 2011. Patient records were reviewed for physician's documentation of the patient's initial and subsequent dose and schedule.
Patient # 5 was admitted July 2, 2011. A standard order was used to order the initial dose and then the increases were left for the nursing staff to implement during the induction phase. The physician's order states: "MMTP build-up order 7/2/11-30 mg, 7/3/11-40 mg,
7/4/11-50 mg, 7/5/11-60 mg."
Patient # 7 was admitted March 25, 2011. A standard order was used to order the initial dose and then the increases were left for the nursing staff to implement during the induction phase. The physician's order states: "MMTP build-up order 4/9/11-30 mg, 4/10/11-40 mg,
4/11/11-50 mg, 4/12/11-60 mg."
Patient # 8 was admitted May 24, 2011. A standard order was used to order the initial dose and then the increases were left for the nursing staff to implement during the induction phase. The physician's order states: "MMTP build-up order 5/25/11-30 mg, 5/26/11-40 mg,
5/27/11-50 mg, 5/28/11-60 mg."
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Plan of Correction
The Medication Dosage policy and procedure was revised to stipulate that there shall be a separate physician's order for each dosage change, and that build-up orders for dose changes during induction are no longer allowed. Notification of this requirement was sent by the operations/facility director to the program physician/medical director, nurse manager, and program coordinator. The clinical director also spoke directly with the medical director, who acknowledged that build-up orders are not to be used. The program coordinator shall monitor compliance through regular clinical record reviews. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on the review of patient records, the facility failed to document annual history and physicals by the physician in three of nine patient records.
The findings include:
Nineteen patient records were reviewed September 19-21, 2011. Nine patient records required an annual physical examination on or about the anniversary date of the patient's admission. Three patient records included documentation the annual physical exam was completed about two months or more beyond the anniversary date of the patient's admission.
Patient # 2 was admitted June 16, 2007. The annual physical exam was completed August 6, 2011. There was no documentation justifying why it was done late.
Patient # 10 was admitted May 6, 2005. The annual physical exam was completed July 19, 2011. There was no documentation justifying why it was done late.
Patient # 14 was admitted April 28, 2007. The annual physical exam was completed August 13, 2011. The prior year annual physical exam was completed June 26, 2010. The patient's counselor referred the patient for the annual physical exam May 23, 2011. There was no other documentation justifying why it was done late.
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Plan of Correction
The program staff developed procedures for improving patients' compliance with keeping their scheduled appointments for the annual physical exams, and the program coordinator instructed staff to document reasons why any individual exams were delayed. The program coordinator is now reviewing a monthly printout of those patients due for their annual exam and will monitor compliance of its completion. |
715.23(d)(2) 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.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Based on the review of patient records, the facility failed to review, reevaluate, modify and update the patients' treatment plans at least every 60 days for three of four patient records.
The findings include:
Nineteen patient records were reviewed September 19-21, 2011.
Patient # 1 last had a treatment plan updated on June 9, 2011. There were no further treatment plan updates as of September 21, 2011.
Patient # 4 last had a treatment plan up June 25, 2011. There were no further treatment plan updates as of September 21, 2011.
Patient # 11 last had a treatment plan up June 29, 2011. There were no further treatment plan updates as of September 21, 2011.
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Plan of Correction
At a recent program team meeting the program coordinator reiterated to staff that they are required to adhere to the timelines for clinical documentation updates, including treatment plans. Any warranted delays need to be clearly documented in the clinical records. The coordinator shall monitor compliance through regular supervision and clinical chart reviews. |