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 February 14-15, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Summit Medical Services 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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715.21 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.
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Observations
Based on the review of patient records and discussion with administrative staff, the facility failed to demonstrate all efforts were effected to retain the patient and that these efforts failed in four of five patient records.
The findings include:
Fifteen patient records were reviewed February 14-15, 2012. Five patient records reviewed were discharged prior to the review. Four were discharged or transferred involuntarily for failure to meet the goals of their "concurrent" treatment plan that addressed failure to pay treatment fees. Facility documentation evidenced that money owed by patients was divided into two payments and the patient was obligated to meet the goal of paying the full amount in four to seven days. There was no documentation of efforts to explore why they got behind in payments, or an assessments of the patient's current ability to pay for treatment.
Patient # 1 was admitted December 2, 2010. While the patient had issues of being absent without leave (AWOL) and use of illicit drugs throughout the treatment stay, the reason for discharge was documented as a failure to follow the the concurrent treatment plan goals and objectives. The concurrent treatment plan goal was written on November 21, 2011 and the patient was required to pay one half of the amount owed on November 23, 2011 and the remainder on November 25, 2011. The physician's order for an involuntary detoxification was written November 25, 2011. The time frame to meet the goal of payment was five days. There was an "action plan" for the counselor to refer the patient for financial counseling to be met in six months, well after the patient received an involuntarily detoxification.
Patient # 2 was admitted July 2011 and discharged involuntarily December 2, 2011. A written notice to pay the treatment fee balance in two equal amounts or be terminated from treatment was given the patient October 24, 2011, with the first payment due October 26, 2011 and the second payment due October 28, 2011. The physician's order to start the involuntary detoxification was documented on October 28, 2011. The patient was discharged involuntarily December 2, 2011 and re-admitted December 6, 2011. The patient received notice of payment requirement on December 26, 2011 with payments to be made December 29, 2011 and January 2, 2012. The patient was started on an involuntary detoxification January 2, 2012.
Patient # 4 was admitted October 4, 2010. The reason for discharge was documented as a failure to follow the the concurrent treatment plan goals and objectives. There were three different concurrent treatment plans established with this patient between October and December with the last resulted in an involuntary detoxification. The first reviewed was written October 21, 2011 for two payments to be made on October 25, 2011 and October 28, 2011. The next concurrent treatment plan reviewed was written on November 25, 2011 and required the patient to pay the first payment on November 30, 2011 and the remainder on December 2, 2011. The final concurrent treatment plan was written December 16, 2011 and required the patient to make two equal payments, the first on December 20, 2011 and the final on December 23, 2011. The patient received a letter of termination on December 28, 2011. The physician's order for an involuntary detoxification was also written December 28, 2011. The time frame to meet the goal of payment was seven days. There was an "action plan" for the counselor to refer the patient for financial counseling to be met in six months on each of the three concurrent treatment plans reviewed.
Patient # 5 was admitted May 10, 2010. The patient was given notice to pay back balance owed on June 20, 2011. The patient was to pay about one half on June 23, 2011 and the remainder June 27, 2011. The patient was the discharged as an involuntary transfer on June 30, 2011.
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Plan of Correction
In addressing this observation, four changes will be outlined to address this issue.
First, upon intake, the SMS Treatment Consent Form will be altered to include a part about costs of treatment. As part of signing this consent, it will be outlined that the patient understands the costs of services rendered and attests that (1) they understand these costs, (2) they are able take responsibility for these costs ongoing and (3) they will inform their counselor if their ability to pay for services rendered changes. The paragraph will go on to say if #3 is the case, they can talk with SMS Clinical Supervisor or Faciltiy Director to develop a reasonable plan to deal with the situation. This agreement will be kept by the clinical supervisor in a binder that will contain agreements made. This form (Treatment Consent) will be changed by the Facility Director and reviewed with staff during the 3/13/12 staff meeting where it will become standard procedure.
Second, the letter given to patients in accordance with the concurrent treatment plan will include a section in which they attest that they have discussed with their counselor re: these issues and they understand that they have the right to meet with the clinical supervisor or the Facility Director regarding an agreement to be made to meet the concurrent treatment goals. This agreement will be kept by the clinical supervisor in a binder that will contain agreements made. Changes to this form (letter) will be made by the Facility Director and will be reviewed in the 3/13/12 staff meeting, where this will become standard procedure.
Third, in the letter given to patients in accordance with the concurrent treatment plan, the conditions of payment will be listed followed by a statement reading they have agreed to this amount and if they have trouble with these conditions, they may request the clinical supervisor or Facility Director to meet with them to come up with a reasonable agreement. This agreement will be kept by the clinical supervisor in a binder that will contain agreements made. The form (letter mentioned above) will be changed by the Facility Director and reviewed with all staff at the 3/13/12 staff meeting, where this will become standard procedure.
Fourth, once the patient is working on concurrent treatment goals, the counselor will have a session addressing goals set to provide appropriate guidance and referrals, as well as reiterate the option for patient to meet with the clinical supervisor or facility director.
These four changes should outline reasonable steps to be taken to ensure all efforts werer made to retain the patient. |
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.
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Observations
Based on the review of patient records, the facility failed to restrict the reasons for involuntary termination to those reasons allowed by regulation in five of six patient records.
The findings include:
Fifteen patient records were reviewed February 14-15, 2012. Six patient records were reviewed for involuntary, or therapeutic, discharge. Five of the six patient records contained documentation of the patient being discharged for reasons other than those listed by regulation.
In addition, all fifteen patient records contained a signed document entitled SUMMIT MEDICAL SERVICES WELCOME GUIDELINES . This document includes two areas in which the facility states there could be an involuntary termination from the program that is not allowed by regulation. On the first page listed under # 5, the facility includes " Attempting to provide a false urine sample will result in loss of privileges from and/or an involuntary detox the program." On the second page under TAKE HOME PRIVILEGES, there is documentation that identified the requirements and responsibilities of take home bottles. It stated "Continued problems in this area could result in the loss of take home privilege status or even involuntary termination from the program." these two reasons for potential discharge exceed the reasons provided, by regulation, for involuntary termination.
Patients # 1, 2, 4, 5, 6 were involuntarily terminated for failure to meet financial obligations for treatment. The facility provided each patient was five to to eight days to make their financial obligations current. The letter of termination stated it was failure to follow treatment plan objectives, but these were the concurrent treatment plans established after the patients accumulated a couple of weeks worth of non-payment. The facility failed to document efforts to assist the patient.
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Plan of Correction
There will be two corrections to the Summit medical Services Welcome Guidelines. The first will be the sentence "Attempting to provide a false urine sample will result in loss of Privileges and/or an involuntary detox from the program," will be removed.
On the second page of the same document under "Take Home Privileges," the sentence "Continued problems in this area could result in the loss of take-home privilege status or even involuntary termination from the program," will be changed to omit the "or even involuntary termination from the program," part.
Both of these changes will be made by the Facility Director on 3/7/12 and reviewed in the upcoming 3/13/12 staff meeting.
Also, the Facility Director will review with all staff during this 3/13/12 staff meeting through staff training the reasons as per state 715.21(1)(i-iv)a patient may be involuntarily terminted from a program. |
715.22(c) LICENSURE Patient grievance procedures
(c) Penalties may not be initiated prior to final resolution with the exception that penalties may be initiated against patients who have committed acts of physical violence or who have threatened to commit acts of physical violence in or around the narcotic treatment program premises.
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Observations
Based on a review of patient records, the facility failed to refrain from initiating penalties prior to the final resolution in two of five patient records reviewed.
The findings include:
Fifteen patient records were reviewed February 14-15, 2012. Five patient records contained documentation of involuntary detoxification orders.
Patient # 1 was admitted December 2, 2010. The patient received notice of need to address financial matters on November 21, 2011. This was the only notice given. This did not include any guidance to appeal the matter. The patient was given an involuntary detoxification that started on November 25, and concluded November 30, 2011.
Patient # 12 was admitted November 22, 2011. The patient was provided with a concurrent treatment December 26, 2011, that required the patient to pay up his/her financial obligation by January 2, 2012. An involuntary detoxification order was written January 5, 2012 without benefit of a termination notice or an opportunity to appeal. The detoxification was started January 5, 2012, but was stopped January 6, 2012. The patient was not discharged at the time of the monitoring.
It was discussed with the administrative staff and it was agreed that notice of termination was not found in the patient records.
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Plan of Correction
As per Summit Medical Services standard procedures, upon a decision for involuntary detoxification, all patients are to be informed in writing of their right to appeal this decision. This was not the case in the observed patient #1 and #12, as no Letter of Termination (which indicates to the patient their right to appeal the decision) was present in the chart.
Due to this oversight in these two cases, the following measures will take place to ensure 100% compiance in this area.
First, all patients when receiving a notice of involuntary detoxification, will have the option reviewed to them in writing to appeal the decision. The patient will sign off on this notice of termination/involuntary detoxification, counter-signed by the SMS physician.
To ensure this process is completed, the SMS clinical supervisor or facility director will also sign to ensure the process has been reviewed with the patient in 100% of the cases.
The forms will be changed by the facility director on 3/7/12 to accomodate these signatures. The facility director will train and review with staff this procedure during the 3/13/12 staff meeting. |
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 complete the annual physical with a re-evaluation by the physician in six of nine patient record reviewed.
The findings include:
Fifteen patient records were reviewed February 14-15, 2012. Nine records were required to have a completed annual physical examination that included a reevaluation by the physician.
Patient # 7 was admitted January 19, 2011. The annual physical exam was completed on January 12, 2012 by the Certified Nurse Practitioner (CRNP), but did not include a re-evaluation by the physician.
Patient # 8 was admitted August 5, 2008. The annual physical exam was completed on August 9, 2011 by the Certified Physician Assistant (PAc), but did not include a re-evaluation by the physician.
Patient # 9 was admitted May 14, 2009. The annual physical exam was completed on May 4, 2011 by the Certified Physician Assistant (PAc), but did not include a re-evaluation by the physician.
.Patient # 10 was admitted January 28, 2011. The annual physical exam was completed on January 3, 2012 by the Certified Nurse Practitioner (CRNP), but did not include a re-evaluation by the physician.
Patient # 11 was admitted December 2, 2010. The annual physical exam was completed on December 14, 2011 by the Certified Nurse Practitioner (CRNP), but did not include a re-evaluation by the physician.
Patient # 14 was admitted January 24, 2011. The annual physical exam was completed on January 3, 2012 by the Certified Nurse Practitioner (CRNP), but did not include a re-evaluation by the physician.
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Plan of Correction
The facility director will, on 3/8/12, review with all medical staff, including the Nurse Practitioner and the medical director the standard practice necessary for completing the annual physical effective immediately (3/8/12).
Summit Medical procedure indicates either the medical director or physician's assistant/nurse practitioner can conduct a patient's annual physical. If the physician's assistant/nurse practitioner completes the annual physical, the medical director will follow up and do the following in 100% of the cases:
1. Re-evaluate the annual with the nurse practitioner to go over any issues, problems or questions.
2. After re-evaluation, the medical director will indicate the dosage the patient is to remain on or if any changes in dosage are necessary.
3. The medical director, after re-evaluation and orders given, will counter-sign the document, thus completing the annual physical procedure.
The facility director will review this procedure with all SMS staff on the 3/13/12 staff meeting to ensure all staff know the procedure. |