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 October 18-20, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Kensington Hospital Outpatient Treatment Program 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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715.11 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 patient records, according to 4 PA Code 255.5 in nine of eleven patient records.
The findings include:
Sixteen patient records were reviewed October 18-20, 2011. Eleven patient records were reviewed specifically for confidentiality compliance. Nine patient records contained signed consents to release information that were not documented to meet the requirements for confidentiality. Patient records # 1, 3, 5, 6, 9, 10, 11, 12 and 16 contained signed consents to release information to the patient's funding agency that contained an expiration date of 30 days after the dated signature. Since the funding agencies require ongoing progress reports for continuing care approval, any information reported to the funding agency after the 30 days of the patient's dated signature was done so without patient's informed consent.
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Plan of Correction
The custodian of files will audit charts weekly, checking one (1) caseload per week. This audit will include the timeframe for the authorization to release confidential information. This policy and procedure was discussed with the clinical staff on 11/18/11 and 12/9/11. The final authority to oversee compliance with this policy and procedure is the Director of Behavioral Health. |
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 the review of patient records, the facility failed to complete a urine drug screen at least monthly in three of thirteen patient records.
The findings include:
Sixteen patient records were reviewed October 18-20, 2011. Thirteen patient records were reviewed specifically for urine drug screen records. Three patient records did not have all of the required monthly urine drug screens.
Patient # 4 was admitted March 25, 2011. There were no documented urine drug screens for June and July 2011 in the patient's record.
Patient # 8 was admitted August 3, 2011. The last documented urine drug screen was dated August 24, 2011. There was no documentation in the patient record for a urine drug screen during the month of September 2011.
Patient # 12 was admitted August 3, 2011. There were no documented urine drug screens since the patient's initial urine drug screen dated August 11, 2011.
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Plan of Correction
The Administrative Assistant will also have in her computer a spread sheet with the dates that each has submitted a drug screen. If they have not submitted one by the third week of the month, a notice of this situation will appear so that a UDS can be scheduled before the end of that month. Also to confirm that a drug screen was submitted, the Administrative Assistant will be given the request forms to secure a UDS from all of our clients so that we can track the results from the request to also insure that a UDS was processed and not lost in the meantime. The Admin. Assist will also document the results of the UDS and give the hard copy of the drug screens to the records clerk to be placed in the clients' charts. This entire process will be monitored and come under the responsibilities of the Director of Behavioral Health.
Completion Date: 11-15-11
This revision of policy and procedure has been covered in a staff meeting in the series of meetings that covered the changes necessary to maintain verification of progress in clients' treatment. Training was held on 10/31/11. |
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 records, the facility failed to ensure the physician completed a semi-annual dose review as required in four of six patient records.
The findings include:
Sixteen patient records were reviewed October 18-20, 2011. Six patient records required at least semi-annual dose reviews.
Patient # 1 was admitted November 22, 1999. There were no documented dose reviews in the patient record presented for review.
Patient # 3 was admitted September 17, 2001. The last two documented dose reviews were dated October 14, 2009 and September 9, 2010.
Patient # 13 was admitted July 21, 2009. There were no documented dose reviews in the patient record presented for review.
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Plan of Correction
Your audit discovering deficiencies in our medication checks with our clients uncovered several charts that were missing the stipulated number of med checks to be completed by the Doctor. Our Administrative Assistant will have a data spread sheet that will alert her to the need to schedule clients for their med checks. Hopefully we will be able to carry out this plan three times in a calendar year to guarantee our clients are at optimum dose of their medication on a more frequent time frame. This entire process will be monitored and come under the responsibilities of the Director of Behavioral Health.
Completion Date: 11-14-11
This monitoring of services has been covered at a staff training on 11/7/11.
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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
Based on the review of patient records, the facility failed to provide the required psychotherapy hours in six of nine patient records.
The findings include:
Sixteen patient records were reviewed October 18-20, 2011. Nine patient records were reviewed for psychotherapy content, to include a minimum of 2.5 hours monthly. Six patient records did provide documentation of counseling that was in accordance with the regulations.
Patient # 4 was admitted March 25, 2011. The patient received only 2 hours of psychotherapy in April and May 2011. The patient did not receive any documented psychotherapy during the months of June, July and August 2011. The patient received only 1 hour of psychotherapy in September 2011.
Patient # 5 was admitted May 4, 2011. The patient has not been seen for psychotherapy since September 7, 2011.
Patient # 6 was admitted August 5, 2011. The patient was seen for 2 hours of psychotherapy in August, 1 hour of psychotherapy in September and 1 hour to date in October, 2011.
Patient # 9 was admitted September 29, 2010. The patient has only received 1 hour per month of psychotherapy since October 2010.
Patient # 10 was admitted December 23, 2010. The patient has only received 1 hour per month of psychotherapy since December 29, 2010. The last session was September 13, 2011.
Patient # 12 was admitted August 3, 2011. The patient has not been seen for psychotherapy since September 19, 2011.
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Plan of Correction
In reviewing this section of the standards for treatment, the staff decided that looking at the treatment recommendations for clients in MMTP will be held at the highest standard for treatment sessions in this level of care. After looking at the different governing sectors in OTP we will begin scheduling clients to attend group sessions for a minimum of two groups- one Psycho-Education and one Psycho-Therapy. Each client will attend the Psycho-Education session with their primary therapist, and one session with a therapist they feel will enhance their chances of getting sober and remaining sober. They will also attend at least one individual session (1:1) on a bi-weekly basis with their primary therapist as well. The primary counselor will track the clients attendance obligations to confirm that their caseload clients are compliant with their treatment schedules. After six months of participating in this level of care, each client will be reviewed to see if they have gained enough insight into the disease and relapse concepts to maintain their recovery in OTP. If the therapist and other members of the treatment team feel that a client has made the measured progress that has been set up in his recovery plan, then those clients will be reduced to one group attendance per week and one individual session bi-weekly. Again the client compliance will be monitored by the primary counselor.
All of the newly admitted clients will begin treatment at this level of care and will also attend all scheduled sessions as described above for individual and group sessions. Clients who originally showed good level of motivation and commitment, but started struggling with such issues as positive drug screens and non-compliance with treatment schedules, may be stepped up to this more intensive level of care. This entire process will be monitored and come under the responsibilities of the Director of Behavioral Health.
Completion Date: 11-15-11
Staff was trained on this topic on 11/7/11. |
715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of patient records, the facility failed to ensure patients were provided with the required psychotherapy in three of three patient records.
The findings include:
Sixteen patient records were reviewed October 19-20, 2011. Three patients required at least 1 hour of psychotherapy every 2 months.
Patient # 1 was admitted November 22, 1999. The patient was not seen for psychotherapy between May 16, 2011 and September 1, 2011.
Patient # 2 was admitted August 29, 2002. The patient has not been seen for psychotherapy since July 27, 2011.
Patient # 3 was admitted September 17, 2001. The patient has not been seen for psychotherapy since January 26, 2011.
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Plan of Correction
Each client engaged in OTP/MMTP at Kensington Hospital will be seen for an individual session at least bi-weekly. This is the most accurate way to measure the client's internalization skills as they relate to material covered in the group sessions. As each client progresses in OTP they will be held less accountable for 1:1 sessions. This will be noted in the frequency of sessions that they will be held accountable to attend as they proceed in treatment.
After two years of compliance with the goals and action steps included in their treatment plan to recovery they will have to be present for one individual or group session per month, as deemed most effective for each individual client. And if they continue in treatment they will be reduced to one session bi-monthly whether it be an individual or group session. This will happen when the client reaches four consecutive years of adherence to program expectations. This entire process will be monitored and come under the responsibilities of the Director of Behavioral Health.
Completion Date: 11-18-11.
Staff was trained on this topic at a staff meeting of 11/7/11. |
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 the review of patient records, the facility failed to ensure the patient record included current progress notes in ten of sixteen patient records.
The findings include:
Sixteen patient records were reviewed October 18-20, 2011. Sixteen records required counselor notes documenting patient's progress and status. Patient records 1, 2, 3, 4, 5, 6, 10, 12, 13, and 14 did not have the patient's most recent progress and status, or there were gaps in the documentation regarding the progress and status of the patient.
Patient record # 1 had no progress notes between May 16, 2011 and September 1, 2011.
Patient # 2 was admitted August 29, 2002 and the last progress note was dated July 27, 2011.
Patient record # 3 had no progress notes between November 25, 2009 and May 26, 2010 or between May 26, 2010 and January 12, 2011. There were no progress notes documented in the record since January 26, 2011.
Patient record # 4 had no progress notes between May 12, 2011 and September 19, 2011.
Patient # 5 was admitted May 4, 2011 and had no progress notes since September 7, 2011.
Patient # 6 was admitted August 5, 2011. There were a total of three progress notes documented in the patient record, 8/12/11, 9/8/11 and 10/5/11.
Patient # 10 was admitted December 23, 2010 and had no progress notes since September 13, 2011.
Patient # 12 was admitted August 3, 2011 and had no documented progress notes since September 19, 2011.
Patient # 13 was admitted July 21, 2009 and was reported by the facility director as being deceased, no date provided. The last day the patient was dosed was documented on July 17, 2011. The last progress note was dated June 29, 2011.
Patient # 14 was admitted March 4, 2005 and was reported by the facility director as being deceased. The information was provided to the funding source on June 27, 2011. The last progress note was documented April 26, 2011.
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Plan of Correction
Each patient file shall include Counselor notes regarding patient progress and status. In several of our client records there were entries in the Record of Services but no DAP note to document what occurred during the session. Each counselor is responsible for including the date of services in the record as well as a DAP formatted progress note for each contact the client had with the counselor. It will be the responsibility of the Director to confirm that a progress note was included in the Record of Services, and this will take place each week that the counselor and Director meet for supervision and record monitoring.
This entire process will be monitored and come under the responsibilities of the Director of Behavioral Health.
Completion Date: 11-15-11
Staf was trained on this topic at a staff meeting on 11/14/11. |
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 ensure the psychosocial evaluations contained a clinical assessment of the historical data collected in seven of nine patient records.
The findings include:
Sixteen patient records were reviewed October 18-20, 2011. Nine patient records were specifically reviewed for psychosocial evaluations. Seven of the nine patient records contained evaluations that were a repeat of the data or what the patient reported without any assessment of the information.
Patient # 4 admitted March 25, 2011, had no evaluation in the record.
Patient # 5, admitted May 4, 2011, contained a document that repeated data and was a list of what the patient reported.
Patient # 6 admitted August 5, 2011, contained a document that focused only on the patient ' s reason for transferring to the facility.
Patient # 7 admitted June 6, 2011, contained a document that repeated data and was a list of what the patient reported.
Patient # 11 was admitted September 22, 2011. The psychosocial evaluation was a repeat of what the patient reported and no evaluation.
Patient # 12 was admitted August 3, 2011. The psychosocial evaluation was a repeat of what the patient reported and no evaluation.
Patient # 16 was admitted September 15, 2011. The psychosocial evaluation was a repeat of what the patient reported and no evaluation.
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Plan of Correction
Each client will undergo a question and answer session during which a complete history will be taken of the client. The document will cover each part of the client's personal, legal, education, employment, substance abuse, sexual, and family history. The information will be used to develop an image of the client that will help develop client Bio-Psycho-Social assessment which will prove instrumental in completing the needs list, treatment and recovery plan, and further enhance the client's chances of reaching and remaining sober and recovering. It should also be noted that the client will be assessed using the information provided by the client pertaining to his personal history as it relates to their Family, Drug Abuse, Legal, Employment/ Vocational, Emotional, and recent history as to why the client has chosen this time to seek treatment as it relates to his drug and alcohol problems.
These question and answer sessions will be scheduled within the first five days of his admission into treatment. This entire process will be monitored and come under the responsibilities of the Director of Behavioral Health.
Completion Date: 11-15-11
Staff was trained on this topic at a staff meeting on 11/14/11. |
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 facility failed to complete a discharge summary in four of four patient records.
The findings include:
Sixteen patient records were reviewed October 18-20, 2011. Four patient records required a completed discharge summary.
Patient # 13 was admitted July 21, 2009. The patient record shows the patient was last dosed July 17, 2011, the last progress note was dated June 29, 2011 and the facility records listed the patient as deceased and discharged. There was no discharge summary completed.
Patient # 14 was admitted March 4, 2005. The patient record shows the last progress note was dated April 27, 2011 and the facility records listed the patient as deceased and discharged. There was a report to the funding agency on June 27, 2011. There was no discharge summary completed.
Patient # 15 was admitted December 10, 1997. The patient record shows the last progress note was dated April 29, 2011 and the facility records listed the patient as deceased and discharged. There was a report to the funding agency on May 24, 2011. There was no discharge summary completed.
Patient # 16 was admitted September 15, 2011. The patient record shows the patient was last dosed September 28, 2011. The facility listed the patient as discharged. There was no discharge summary completed.
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Plan of Correction
In the event of a client discharging from our services, the therapist will complete a discharge summary within 7 days of the client's discharge date. This will be done for all clients under all circumstances of discharge.
The clinical staff discussed and became aware of this standard at a staff meeting on 12/12/11.
The Clinical Director will monitor this issue to assure compliance through random monthly chart reviews. |
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, the facility failed to ensure the annual evaluations were completed as required in six of seven patient records.
The findings include:
Sixteen patient records were reviewed October 18-20, 2011. Seven patient records were reviewed for documentation of annual evaluations on or about the patient ' s anniversary date. In addition, all seven required the medical director review and sign. Six did not have a physician signature.
Patient # 1 was admitted November 22, 1999. The last annual evaluation was dated November 22, 2009.
Patient # 2 was admitted August 29, 2002. The last annual evaluation was dated October 10, 2009.
Patient # 9 was admitted September 29, 2010. There was no documented annual evaluation, due no later than September 29, 2011.
Patient # 13 was admitted July 21, 2009. The annual evaluation was dated November 4, 2010, more than three months after it was due.
Patients # 14 and 15 contained annual evaluations that failed to have a physician sign off as required.
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Plan of Correction
A data base has been put into place to track client activities that need to be completed in a timely fashion. One of these functions is the annual evaluation that will be tracked by the administrative assistant to guarantee the compliance with this activity being completed as prescribed by Licensing. My assistant will put together a list of clients who have an admission date that is included in the list of admissions for the upcoming month. For example, in November there will be a list of clients generated with an admission date in December. The clients included in this list will be given a date in December subsequent to their admit date to have the clinical evaluation completed as well as their assigned date for a medical evaluation with the Medical Director of the MMTP. All of this information will also be stored in the spread sheet to insure that this activity will be completed in the prescribed time frame. The Behavioral Director will review these statistics by the beginning of the third week of the month. The Director will inform the assistant of any missing data, signatures, or any missing prognosis or evaluations that may prove vital in future treatment planning.
The areas of the client's personal history subject to review will include education, employment, training, changes in legal status, substance abuse, financial management, fulfillment of treatment goals through the preceding year in treatment, and any new supports that may have been brought into the client's recovery.
This entire process will be monitored and come under the responsibilities of the Director of Behavioral Health.
Completion Date: 11-30-11
Staff was trained on this issue at the staff meeting of 11/14/11. |
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 a review of patient records, the facility failed to document the progress or lack of progress in achieving the goal statements from the prior treatment plan in ten of fourteen patient records.
The findings include:
Sixteen patient records were reviewed October 18-20, 2011. Fourteen patient
records were reviewed for treatment plan updates.
Patient record # 1 had a treatment plan update documented on 4/23/2011 This was not updated again until 9/1/2011. The treatment plan update was due by 6/23/2011, at least every 60 days.
Patient record # 2 had a treatment plan update documented on 8/29/2011. The update did not include the patient's progress related to the stated goals and objectives.
Patient record # 3 had a treatment plan update that did not include the patient's progress related to the stated goals and objectives.
Patient # 4 was admitted March 25, 2011 and had no treatment plan updates.
Patient record # 5 was to have a treatment plan update by October 5, 2011. The last update was dated August 5, 2011.
Patient record # 10 had a treatment plan update documented on 8/29/2011. The update did not include the patient's progress related to the stated goals and objectives.
Patient record # 12 had a treatment plan update documented on 9/9/2011. The update did not include the patient's progress related to the stated goals and objectives.
Patient record # 13 was to have a treatment plan update by July 4, 2011. The last update was documented May 4, 2011. The update did not include the patient's progress related to the stated goals and objectives.
Patient record # 14 was to have a treatment plan update by April 15, 2011. The last update was dated February 15, 2011.
Patient record # 15 had treatment plan updates with the identical progress notes March 1, 2011 and May 2, 2011 despite progress notes discussing significant changes in the patient's status. These changes should have been addressed in the treatment plan updates. In addition, there was no progress information documented December 29, 2010.
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Plan of Correction
A data base has been constructed to follow each client's progress in treatment as it relates to a timely completion of treatment planning. A treatment plan for each client in our MMTP level of care will be updated in a maximum of 60 days. The therapist will be notified by the administrative assistant when a treatment plan is due during the upcoming month. The listing for updating, past due, and completed treatment plans will be highlighted by a color coding which will be completed at the clinician's clinical supervision with the Director. Should any significant changes occur in the client's life, a new Treatment Plan update or an addendum to the current Plan will be documented and will be signed by the appropriate personnel, including the client.
Also included in the revised treatment plan form, there is a section showing how long the treatment plan is in effect. There is also a list of what supportive groups and actions could be included to enhance the client's chances of successfully completing their pursuit of goals in their TPU.
This entire process will be monitored and come under the responsibilities of the Director of Behavioral Health.
Completion Date: 11-30-11
Staff was trained on this issue at the Staff meeting of 11/14/11. |
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 the review facility documentation that included incident reports, and staff discussions, the facility failed to provide documentation of incident reports involving death to the Department.
The findings include:
During the October 18-20, 2011 methadone monitoring, the facility had documentation of incident reports that identified patient deaths. Patients # 13, 14 and 15 died while active in treatment. The facility failed to provide the Department with a written report that provided an account of the patient's death.
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Plan of Correction
An unusual incident report will be documented in the occurrence of any of the following:
Complaint of patient abuse (physical, verbal, sexual, and/or emotional)
Death or serious injury due to trauma, suicide, medication error or unusual circumstances
As a result of a fire or any storm damage that would interfere with the normal provision of services that would normally take place.
Incidents leading to negative community reaction
Drug hospitalization of a patient.
Any information, whether considered reliable or unreliable, will be looked into to see if such an occurrence happened to any of our clients. If this is found to be true an Unusual Incident Report will be completed by the therapist of the person involved in the incident. It will be completed within 24 hours of the first reports of the occurrence and forwarded to all reguired regulatory agencies, as well as any other agencies who have a vested interest in the person involved in this incident. It will become the Behavioral Director's responsibility to carry through on the completion of the form and seeing that it is sent to Harrisburg.
Staff was trained on this issue at the Staff meeting of 11/15/11.
Completion Date: 11-30-11
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