INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use a narcotic agents, specifically methadone, in the provision of outpatient maintenance treatment for opioid dependence. This inspection was conducted on December 16-18, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, JF Kennedy Community MH/MR Center 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 January 15, 2009. .
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Plan of Correction
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of administrative documentation and discussions with the facility director and his supervisor, the facility failed to provide the physician's time sheets for review.
Findings include:
The policy and procedure manual was reviewed, as well as other administrative documentation requested, on December 16, 2008, and again on December 18, 2208. The facility did not provide the requested physician time sheets for review to determine compliance with the 1 hour per week onsite services for every ten patients.
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Plan of Correction
Copies of doctors time sheets are maintained in the payroll department at our main office. Effective 1-26-2009 we will keep copies of the doctors time sheet at 907 N Broad St for review. The Division Director will be responsible for ensuring compliance. |
715.9(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
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Observations
Based on the review of patient records and discussion with the director, the facility failed to contact the previous narcotic treatment facility for the treatment history in one of one patient records.
Findings include:
Twelve patient records were reviewed on December 16-18, 2008. Contact with a previous narcotic treatment program was required in one patient record. The facility did not contact the prior treatment provider to obtain the patient's treatment history in patient record # 4.
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Plan of Correction
The JFK Methadone Clinic has developed a policy and procedure to ensure that a treatment history is requested for every patient who reports previous enrollment at a narcotic treatment program. Our Intake Specialist will be responsible for obtaining patient consent and forwarding a request for treatment data (at intake) to the previous treatment program. The patient's consent and JFK's request for treatment information will be a permanent part of the patient's JFK record. The Clinic Director is responsible for training our intake staff and ensuring compliance. |
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 the review of patient record documentation, the facility failed to ensure the physician completed a dose review at least twice yearly for all patients.
Findings include:
Twelve patient records were reviewed December 16-18, 2008. Twice yearly dose reviews were required in eight patient records. The facility did not complete the dose reviews in patient records # 7, 9 and 12.
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Plan of Correction
Our nursing staff will enter six month dosage level review dates into our computer system for each patient. Nurses will monitor this data weekly and schedule patients to see the physician for a dosage review at least two times annually. The Clinic Director will monitor this procedure to ensure 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 the review of patient records, the facility failed to restrict the initial administered dose to that required by Federal regulation 42 Part 8, sub-section 8.12(h)(3)(ii).
Findings include:
Twelve records were reviewed on December 16-18, 2008. Adherence to restricting the initial dose to no more than 30 milligrams was required in one patient record. The facility physician initiated the dose at 35 milligrams and did not include any documentation of a justification in patient record # 1.
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Plan of Correction
The physician that created our non-compliance in this area recently resigned. However, the Division Director has discussed federal restrictions on the initial methadone dose of no more than 30 mgs with our present physicians. These physicians will continue to comply with initial dose restrictions. The Division Director has also reviewed initial dose restrictions with our nursing staff who will serve as a back-up for our physicians to ensure compliance. The Clinic Director will monitor medical records of each new patient to frurther 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 the review of patient records, the facility failed to document a psychosocial evaluation in two of three patient records.
Findings include:
Twelve patient records were reviewed on December 16-18, 2008. Psychosocial evaluations were reviewed in three patient records on December 16 and 17, 2008. The narcotic treatment program did not include clinical assessments in all the areas of the psychosocial evaluations in patient records # 3 and 4. Instead, the documentation was a repeat of the historical data collected and patient reported statements.
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Plan of Correction
Dr. Winston Collins has revised the program's psychosocial histories/evaluation. The evaluation section has been redesigned to present a clear clinical picture of the patient's treatment problems/needs that were derived from historical data. Dr. Collins will provide three training sessions for clinical staff to improve their patient evaluation skills. The Clinic Director will monitor psychosocial evaluations to ensure compliance. |
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 the review of patient records, the narcotic treatment program failed to document discharge summaries that included all the required areas in two of three patient records.
The findings include:
Twelve patient records were reviewed on December 16-18, 2008. Discharge summaries were required in three patient records. The narcotic treatment program did not document discharge summaries that included all the required areas in patient records # 5 and 6.
In patient records # 5 and 6 the discharge summaries did not include the patient's response to treatment and the complete reason for the patient's discharge.
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Plan of Correction
The Division Director will provide two staff trainings to improve their skills at completing patient discharge summaries. Many of our staff are new and would benefit form such training. The Clinic Director is responsible for reviewinag all patient discharge summaries to ensure compliance. |
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 narcotic treatment program failed to document treatment plan updates in six of nine patient records.
The findings include:
Twelve patient records were reviewed on December 16-18, 2008. Treatment plan updates were required in nine patient records. The narcotic treatment program did not document in the treatment plan updates the patient's progress in relationship to the stated goals in patient records # 2, 3, 9, 10 and 12.
Patient record # 4 did not have a treatment plan update that was due by 11-28-08 at the latest.
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Plan of Correction
Beginning 2-27-09, the Clinic Director will review the status of all treatment plans for each patient to ensure timely completion. Treatment plan reviews will be checked on a monthly basis, thereafter, to ensure compliance.
The Division Director will also provide three staff training sessions to assist new staff to document the patient's progress in relationship to the stated goals. |