INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection pertaining to the plans of correction for the October 14, 2011 follow-up to the July 5, 2011 complaint investigation and the February 21 through February 23, 2012 methadone monitoring inspection. The follow-up inspection was conducted on May 14 through May 16, 2012 by staff from the the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, A.R.S. of Lancaster, LP 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.
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Plan of Correction
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715.14(a)(2) 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.
(2) If the narcotic treatment program determines that other drugs are abused in that narcotic treatment program 's locality or have been identified in the patient 's drug and alcohol history as being a drug of abuse or use, a narcotic treatment program may conduct a test or analysis for other drugs as well.
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Observations
Based on the review of patient records, the facility failed to complete an initial drug-screening urinalysis that included other drugs that were identified as being abused by the patient in the drug and alcohol history.
The findings include:
Twenty-two patient records were reviewed on May 15 through May 16, 2012. Ten patient records were reviewed for an initial drug-screening urinalysis that included drugs that had been identified in the patient drug and history as being a drug of abuse or use. The facility failed to include Suboxone in the urine drug screen for patient # 2.
Patient # 2 was admitted on February 21, 2012. The drug and alcohol history completed on February 21, 2012 listed suboxone as the patient's drug of choice. The patient's urinalysis was negative for opiates. An instant drug screen was completed on February 16, 2012 for Suboxone. The instant test was positive, however, the facility failed to include the patient's drug of choice, Suboxone, on the urinalysis drug screen. In accordance with the regulations,
drug-screen urinalysis must be completed by an approved laboratory.
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Plan of Correction
During the admission process, the physician will clearly document drug of choice and any reasons for the use of the exception process for admission. Regardless if an exception is permitted under the regulation, the medical department completes an initial urinalysis on all possible admits that includes a screen for opiates, methadone, barbiturates, cocaine, amphetamines and benzodiazepines. In cases when admission candidates report the use of other substances, the medical department will evaluate the need to include these substances in the initial urine analysis test panel. When the medical department concludes that testing for additional substances is necessary, the testing will only be done through the use of an authorized lab. All medical sections of the medical records of patients will continue to be reviewed within 24 hours by the Director of Nursing for compliance which includes whether the initial urine drug screen analysis meets admission requirements. Effective June 12, 2012, if the initial urine drug screen does not meet the requirements, the director of nursing is responsible for ensuring the physician has documented the rationale for the exception. |
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 the review of patient records the facility failed to ensure the narcotic treatment physician determined the proper dose and schedule.
The findings include:
Twenty-two patient records were reviewed on May 14 through May 16, 2012. Patient # 20 was admitted on October 20, 2011. He was admitted into the facility's six month detoxification program. A review of patient record # 20 included a progress note written on March 28, 2012. The documentation stated that the patient met with his counselor to discuss his desire to switch from the detox protocol to the methadone maintenance. In the written assessment of this meeting, the counselor advised the patient that the clinical director was not comfortable allowing the patient to change treatment at that time due to his large financial balance, his positive urine drug screens, and group non-compliance. The counselor advised the patient to complete a dose evaluation form to stop his methadone taper temporarily. This record reflected that the doctor did not make the determination to allow the patient to change the course of treatment and that the clinical director made the decision to not allow his request. There was no documentation in the record that showed that the physician was involved in the decision determining whether or not the patient was allowed to switch treatment from detox to maintenance. The record did indicate the dose request was reviewed by the physician and the patient was granted a stop on his detoxification.
Further review of the record indicated the counselor documented a progress note on April 26, 2012. This note stated the patient was not ready to complete detoxification and requested an additional month of detoxification from methadone. The progress note documented that the counselor consulted with the clinical director who denied this request. The counselor explained to the patient that he had already been granted a one month extension and that during that month he did not make any gains with his financial balance continued to use illicit drugs. The patient's record did not contain documentation that the physician was involved in the determination of the patients's treatment.
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Plan of Correction
To ensure all program requests made by patients are reviewed and approved by the physician, patients will be scheduled to meet with the physician to discuss the option of making a change in the course of their medication treatment. The outcome of this appointment, including the physician's determination will be documented in a medical progress note. The responsible party for monitoring this process is the Director of Nursing. Counseling and medical staff will be trained on this process by June 18, 2012.
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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 ensure all efforts had been initiated to retain the patient prior to the involuntary termination in one of two patient records.
The findings include:
Twenty-two patient records were reviewed May 14 through May 16, 2012. Two patients were involuntarily terminated.
Patient # 15 was admitted on February 4, 2011. Documentation in patient record # 15 indicated the patient received an involuntary termination notice on April 23, 2012, the result of a failure to follow treatment plan objectives. A review of the patient record revealed the patient was, in part, discharged for financial reasons. The patient received a termination notice that indicated the following reasons for discharge: Failed four behavioral contracts and two financial contracts. The patient was to also admit herself to inpatient treatment but has failed to do so in five weeks time. The patient continued to use illicit drugs, carry a large balance ($660) and had not attended group counseling since July 2011. The annual review completed on February 4, 2012 also referenced that the patient has medical assistance, but had a balance and had made little progress paying it down regardless of the fact that the balance is not accumulating. The discharge summary written on May 7, 2012 also stated the patient's treatment goals included financial issues with the clinic and the patient carried a large balance which she had not paid. There was documentation in the record that the patient did attempt to get on waiting lists for inpatient treatment. Documentation in the patient record reference that her counselor reported to the patient on April 5, 2012 that a treatment facility was trying to get in contact with the patient. There was no additional documentation regarding the patient's attempts to go to inpatient treatment. The facility did not document sufficient attempts to work with this patient in order to retain them in treatment.
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Plan of Correction
All potential involuntary discharges that do not involve:
- acts or threats of physical violence
- possession of a controlled substance
- Or absence from the program for 3 consecutive days or longer without cause
will be reviewed by Executive Director, Clinical Supervisor and physician prior to presentation to team to ensure that documentation within the record reflects all efforts made to try to retain the patient in treatment. No patient will be discharged due to financial reasons. Patients will only be involuntarily discharged as permitted under this regulation after all interventions are exhausted. This review will be documented within a case consultation form that will list all of the interventions that have been made to retain the patient in treatment.
The clinical and medical staff will be trained in this new procedure prior to June 18, 2012. The executive director will audit 100 percent of the records of involuntary discharges prior to discharge to ensure on-going compliance with this procedure.
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709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on the review of patient records, the facility failed to document a verbal order accurately.
The findings include:
A verbal order was documented in patient record # 3. The order was written on March 13, 2012. The order stated, "c/o vomiting, tearing, diarrhea, muscle aches, cravings, 19 mg increase approved." This order was signed off within 24 hours, however, the order was written incorrectly. According to the documentation entered in the computer system, the patient was only to receive a 10 mg. increase. The doctor failed to correct the incorrect information on the the written order prior to the attestation.
An interview with the director of nursing confirmed this finding and indicated that the patient received the proper dose. The finding was not disputed.
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Plan of Correction
Prior to June 11, 2012, the Director of Nursing will train all medical staff to ensure that subsequent to printing the physician order for physician signature, the medical staff member who received and entered the verbal order into the automated dispensing system will proof read the order for any typographical errors. If typographical errors are noted, the staff member will edit hard copy order using pen and initial any edits made. The physician will also initial any edits made by medical staff processing the order. Any typographical error noted by physician which was not corrected by medical staff member entering the order may be edited and initialed in pen by the physician.
Compliance with this process will be monitored by the Director of Nursing on an on-going basis.
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