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 December 10, 11, and 12, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHJ Medical Center, Inc. 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 corrections are due on January 11, 2008.
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Plan of Correction
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715.10(c) LICENSURE Pregnant patients
(c) Counseling records and other appropriate patients records shall reflect the nature of prenatal support provided by the narcotic treatment program.
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Observations
Based on a review of three records of pregnant patients, the facility failed to provide treatment plans for patients #16, 27, and 28 that included pregnancy issues and addressed the patient's treatment during pregnancy.
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Plan of Correction
The facility will utilize a process of training and continuous monitoring to obtain and remain in compliance with this regulation. The project director will be the responsible party. There will be a training scheduled with the counseling staff to educate them about the standard. Two months following the training there will be an audit of all pregnant clients records to ensure that the clients treatment and pregnancy issues are being addressed on the treatment plan. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of twenty eight patient records, the facility failed to provide documentation for each patient that the physician made the dose determinations. Specifically, the facility had a form that documented dose reviews and requests for adjustments; the form was completed by staff with specific dose increase recommendations documented on the form. Following a review by the physician, he circled "approve" or "disprove" and provided his signature to the documentation. The physician must make the determination for specific dose changes and the physician must decide the amount of the increase or decrease.
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Plan of Correction
The project director will review and update the client dosage request form to better reflect that the counselors are only providing information to the physician, who determines the clients dosage. A training will be held to review the updated form and provide copies to all staff. All copies of the old form will be destroyed and implimentation of the new form will be monitored by supervisiory staff. |
715.16(b)(1-8) LICENSURE Take-home privileges
(b) The narcotic treatment physician shall consider the following in determining whether, in exercising reasonable clinical judgment, a patient is responsible in handling narcotic drugs:
(1) Absence of recent abuse of drugs (narcotic or non-narcotic), including alcohol.
(2) Regular narcotic treatment program attendance.
(3) Absence of serious behavioral problems at the narcotic treatment program.
(4) Absence of known recent criminal activity.
(5) Stability of the patient 's home environment and social relationships.
(6) Length of time in comprehensive maintenance treatment.
(7) Assurance that take-home medication can be safely stored within the patient 's home.
(8) Whether the rehabilitative benefit to the patient derived from decreasing the frequency of attendance outweighs the potential risks of drug diversion.
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Observations
Based upon review of the policy and procedure manual and review of 16 patient records, the facility failed to rescind take-home privileges for patient # 21 despite the documentation of positive urine drug screen results that confirmed illicit drug use. The patient did did not meet the criteria for take-home privileges.
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Plan of Correction
The project director will delegate to the clinical supervisor the responsibility to maintain oversight for any counselor caseload that is unmanaged due to staff illness or turnover. The project director will then randomly check on any caseload that does not have a counselor to ensure that the clinical supervisor is performing this task. |
715.23(b)(2) LICENSURE Patient records
(b) Each patient file shall include the following information
(2) A complete drug and alcohol history.
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Observations
Based on a review of patient records, twelve of twelve charts reviewed contained drug and alcohol histories that failed to document patient's progression of use and other specific details of patient addiction. The drug and alcohol histories were completed by the patient as part of the intake process; the assigned counselor reviewed and signed the document but did not enter additional details or information on the document to ensure a complete drug and alcohol history was documented.
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Plan of Correction
The project director will review and evaluate the intakae drug and alcohol history documentation. Any updates or changes necessary will be completed. A training will then be held to review any updates or changes to the form. In this training there will be a discussio of the importance of counselors upon intake reviewing the clients statements for accuracy and completion. A random audit will then be conducted to ensure proper documentation of clients drug and alcohol history. |
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 a review of eight patient records, the facility failed to provide patients #3 and 4 with annual physical evaluations.
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Plan of Correction
In order to resolve this deficiency the Project Director will hold a meeting to instruct all staff on tracking annual physicial evaluations. Counselors will be responsible to ensure that clients on their caseloads are scheduled with the physician. The Physician Assistant will cover early hours to ensure clients ability to complete annual physicials in a timely manner.In addition the counselors will document completion of the annual exam on the report and return to the clinical supervisor for tracking. The clinical supervisor will notify the project director if there are any issues.
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715.23(b)(22) LICENSURE Patient records
(b) Each patient file shall include the following information:
(22) Aftercare plan, if applicable.
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Observations
Based on a review of eight patient records, the facility failed to provide aftercare plans that were specific to the needs of the patient at the time of their discharge. The plans contained generic information that was completed at admission. Patients # 15, 16, 23, 24 and 25 were discharged without benefit of an individualized aftercare plan.
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Plan of Correction
The project director will schedule a staff training on aftercare planning.
To ensure staff comprehension an quiz will be completed after training. To ensure continued compliance client discharge charts will be reviewed and the aftercare plans will be evaluated by supervisory staff. |
715.23(d)(1) 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.
(1) The treatment plan shall identify the behavioral tasks a patient shall perform to complete each short-term goal.
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Observations
Based on record review of eighteen patient records, the facility failed to provide treatment plan documentation that provided measurable goals, action steps and support services for patients # 1, 2, 6, 8, and 11.
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Plan of Correction
The project director will review and update the treatment plan form as necessary. A staff training will be held on treatment planning to raise the level of understanding and competence of staff. Supervisors will continue to sign off on all treatment plans. Supervisors will trend any insufficiencies and notify the project director of the need for any further training. |