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 and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on July 31 and August 1 and 2, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northwestern Human Services of Philadelphia 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 August 19, 2007.
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Plan of Correction
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715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
The facility failed to verify the identity, address and date of birth for patient #11 and patient #13. Patient #10 provided a self-made ID card that consisted of a picture taped to a local convenience store name card.
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Plan of Correction
The program was not in compliance with the standard due to an oversight in the Intake department. The project is in full compliance with the standard effective 8/2/2007. Management has trained the department on which forms of identification are acceptable as well as updated the Intake Chart Audit to include a check off verification for the consumer's valid identification. If consumers present without a valid identification card the Intake Specialist will inform them that they must bring it in the following day in order to see the physician and complete their admissions process. The Intake Chart Audits will be reviewed by the Clinical Supervisor daily for follow up and continuity in this process. |
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
The facility failed to document the basis for determination of current dependency for patient #5. This patient's initial urine drug screen results, at the time of admission, were negative for opiates and methadone; hence, there was no documentation of current dependency.
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Plan of Correction
Effective 9/24/07 the project is in full compliance with the standard.
Correction:
The project physician will only admit a patient after verification of age being at least 18 years,verifying the identity, obtaining a drug use history and current drug use status, making a face to face determination of whether the individual is currently physiologically dependent upon a narcotic drug via Positive Drug Screen results and has been physiologically dependent for at least one year prior to admission for maintenance treatment. The physician shall document in the patient's record the Basis for the Determination of current dependency and evidence of a 1 yr hx. of addiction.
The Medical Director will be responsible for continued training and supervision of the staff physicians. The Triage Nurse will review the physician's admission documentation prior to escorting the client to dispensing for their initial dose of medication. She will bring any discrepencies to the attention of the physician and Program Director. The Clinical Supervisor and Program Director are responsible for reviewing all intake and admission documentation. |
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
The facility failed to obtain a consent to release information in thirteen of thirteen patient records reviewed, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 and 13, for the dual enrollment contact ( facilities need to verify that a patient is not enrolled in another narcotic treatment program is the same geographic area) and the reporting of communicable diseases. This form that the facility used to release information was a general consent to release and did not specify who would receive the information, what information would be released and did not contain the required statements related to 42 CFR 2.22.
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Plan of Correction
The project was not in compliance with the standard due to the Dual Enrollment Release also addressing the reporting of comminicable diseases,the specific name of the person who was receiving the release was not placed on the document, and it did not contain the required confidentiality statements.
Correction:
Effective 8/30/07
The Dual Enrollment Release of information was revised.It contains the required statements related to 42 CFR 2.22. Any language referring to communicable disease reporting has been omitted and,the form now contains the specific name of the person who will receive the release.
Intake clerks have been directed not to use any release where they have made changes without the approval of management.
The Program Director will monitor this process to assure continued compliance. |
715.20(4) 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.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
The facility failed to provide documentation that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose for two of five patient records reviewed, #1 and 7.
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Plan of Correction
The project was not in compliance with the standard because it did not document that it notified the transferring narcotic treatment program of patient admissions.
Correction:
Effective 8/3/07
Transfer Client's Notification of Admit & Date of Initial Dose was added to the Intake Chart Audit Sheet as a check off box.
When reviewing the intake charts at the end of each week, the Clinical Supervisor will assure that the box is checked and the faxed information is in fact filed in the client's chart.
The Program Director will monitor this process weekly for ongoing compliance. |
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
The facility failed to provide the minimum seven day detoxification for one of two patient records reviewed, patient #12.
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Plan of Correction
The project was not in compliance with the standard due to not providing the minimum seven day detoxification for a patient.
Correction:
Effective 8/3/07
The facility will provide the minimum seven day detoxification.
The staff have been informed that if the client is not available to receive the notification personally the Letter of Intent to Terminate & Appeal Process should be mailed to the client's last documented address and a copy should be maintained in the chart.The staff will also attempt to reach the client by phone. The staff also received training on how the notification, appeal, and minimum 7 day detoxification is processed.
This same information was also explained, by the Clinical Supervisors, to each group of clients.
The Program Director and the Consumer Satisfaction Committee will be responsible to monitor this process for ongoing 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
The facility failed to develop an evaluative assessment in five of eight psychosocial evaluations reviewed in patient records #1, 3, 6, 11, and 13. Instead, the evaluation was a repeat of patient reports, historical and observational data.
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Plan of Correction
The project was out of compliance with the standard due to counselors misunderstanding of how to evaluate the biopsychosocial and the listed documents not being thoroughly reviewed by management.
Effective 8/31/07 the program is in full compliance with the standard. Monday team meetings included a
"How To" segment addressing documentation. The counselors received training on the Biopsychosocial Evaluation and support through document reviews during weekly supervision.
The Clinical Supervisor is responsible for reviewing the evaluation and supporting counselors to meet the standard.
The Program Director is responsible for assuring that all counselors receive the necessary traings and ongoing supports. |
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
The facility failed to file a written Unusual Incident Report with the Department for several incidents such as the death of a patient and a drug-related hospitalization of a patient that require reporting both by regulation and by the facility's policies and procedures.
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Plan of Correction
The project was out of compliance with the standard because it did not file a written Unusual Incident Report for several incidents such as the death of a patient and a drug related hospitalization of a patient.
Correction:
All employees have been instructed on how to timely and appropriately complete an Incident Report, which types of incidents are considered unusual and must be forwarded to the DOH according to the standard. They were also trained how and where to list the reports with the Safety Committee and forward to management.
Effective September 1, 2007 All Unusual Incident Reports will be forwarded to the DOH within 24 hrs.
of the incident, either via fax or
U. S. Mail.
The Program Director and the Safety & Risk Management Committee will be responsible for monitoring ongoing compliance of this process. The Program Director will be responsible to assure all Unusual Incident Reports are forwarded to the DOH within 24 hrs. |