INITIAL COMMENTS
|
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 25, 26, and 27, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Narcotic Addict Rehabilitation Program of Thomas Jefferson University was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on October 19, 2007. .
|
Plan of Correction
|
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.
|
Observations
Based on a random review of 25 patient records, the facility failed to ensure the narcotic treatment physician documented the rationale for permitting take home medication in records # 1, 2, 3, and 11.
|
Plan of Correction
The narcotic treatment physician, along with the facility director, will create a new take home request form which will include a space for the physician to document why a take home is given. In addition, it will clarify whether this take home has been earned through meeting requirements or if it is an exception due to medical or other emergency conditions necessitating the granting of take home medication. This form will replace presently used forms. |
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.
|
Observations
Based on random review of patient records, the facility failed to include the required components of the patient record for patient # 15's transfer to another narcotic treatment program. Specifically, the dosage level, exception requests, if any, and the patient's current status were missing.
|
Plan of Correction
The one patient record which failed to have sent to the receiving program all materials required, was being transferred to a New Jersey Program which requested some of the material required in Pennsylvania, not be sent. Staff will be retrained by the facility director to know that all transfers, regardless of where the receiving program is located, will be sent the following: The discharge summary, transfer summary, laboratory study results, Urine Analysis results, last three months of treatment plans, physical exam, psychiatric exam and other material as indicated. Only the fax transmittal cover sheet specifying these items have been sent will be allowed to be used when sending material to a receiving program. |
715.21 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.
|
Observations
Based on random review of 25 patient records, the facility failed to document that all efforts to retain the patient in the program had been initiated prior to an involuntary terminations for patients # 5, 6, 7, 14, and 18.
|
Plan of Correction
Facility Director and Director of Training,will conduct on-going trainings clinical staff. Training will include exploring stages of change and action steps for each stage of change,to improve attainment of treatment goals. Terminations for behaviors other than violence or sales of substances of abuse on or near the premises, will be initiated only when all other efforts to retain the patient in the program have failed. Treatment plans will include action steps and timeframes which are accomplishable by the client. Patients failing their treatment plan will be placed on a contract. Contracts will be rewritten as needed as long as patient is willing to try to meet agreed upon treatment goals. Upon failing three or more contracts for behavior change, the client will be asked to transfer to a more appropriate level of care or, refusing this, be detoxified and terminated from the program. These contracts and potential termination will be reviewed by facility director, senior clinician and other clinical supervisory personnel such as Medical and Associate Medical Directors during weekly supervision session. |
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.
|
Observations
Based on random review of 25 patient records, the facility involuntarily terminated patients for reasons not permitted by regulation. Specifically, patient # 6 was involuntarily terminated for not attending sessions and was using illicit drugs, # 14 was involuntarily terminated for non-payment of fees, and # 18 was involuntarily terminated for using illicit drugs.
|
Plan of Correction
Facility Director and Director of Training, will conduct multiple trainings for cliical staff and on-going trainings for new employees. Training will include exploring stages of change and appropriate action steps for each stage of change, to improve the attainment of treatment goals. Involuntary termination will only occur for behaviors other than those deemed not to be in the best interests of the health or safety of the patient and others, of if the patient has committed or threatened to commit acts of physical violence in or around the narcotice treatment program premises, or (ii) the patient possessed a controlled substance without a preseciption or sold or distributed a controlled substance, in or around the nacotic treatment program premises or (iii) the patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause or(iv) failed to follow treatment plan objectives. All proposed involuntary terminations will be reviewed by clinical supervisory staff to ensure compliance with the above specified procedures. Any patients not meeting the criteria for involunatry discharge will be placed on contract by their counselor and changes made in their treatment plans to specify treatment expections, objectives and goals. |
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.
|
Observations
Based on random review of 25 patient records, the facility failed to complete the required annual physical examination in a timely manner. In particular, patient # 10 was admitted June 1, 2004 and her last annual physical examination was completed September 8, 2006. Patient # 11 was admitted February 26, 2005 and his annual physical examination was completed March 23, 2007. Patient #3 was admitted July 15, 2005 and the last annual physical was completed November 6, 2006 with the prior annual examination done August 2005.
|
Plan of Correction
Beginning in November, all patients admitted during the following calendar month,regardless of year of admission, will be listed and scheduled for an annual physical examination by the Medicating Assistant Coordinator. This annual physical will be scheduled at least two weeks prior to the actual anniversary of admission date. Any patient who is unable to attend this physical examination due to being detained elsewhere, such as in a hosptial, prison or rehabilitation program, will have this documented in their chart by the Medicating Assistant Coordinator. The patient will be re-scheduled to complete their annual physical examination within 5 working days of their return to this program as verified by the medical director. |
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.
|
Observations
Based on random review of patient records, the facility failed to complete an annual evaluation for patient #10 which was due in June 2007.
|
Plan of Correction
The Program Coordinator and Senior Clinician will remind staff at the beginning of each month to review records of patients admitted in that calendar month and complete the required annual evaluation for each patient. They will then randomly review various records of patients admitted during that calendar month and again remind counselors to complete annual reviews when appropriate. |