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 January 16-18, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Aldie Foundation Inc. 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.
|
Plan of Correction
|
715.6(c) LICENSURE Physician Staffing
(c) A narcotic treatment physician shall be otherwise available for consultation and verbal medication orders at all times when a narcotic treatment program is open and a narcotic treatment physician is not present.
|
Observations
Based on the review of patient records, the facility failed to ensure a narcotic treatment physician was available at all times when the program was open and a narcotic treatment physician was not on site.
The findings include:
Sixteen patient records were reviewed January 16-18, 2013. Sixteen records were reviewed for documentation of medication orders.
Patient # 13 was admitted November 18, 2010. The patient was given exception take home medication for travel outside of the country for a family funeral. The patient was three days overdue returning to the facility for dosing. The nursing staff noted an attempt was made to contact the back up physician at all the numbers they had available, to no avail.
Upon discussion with facility staff, it was noted the weekend staff had always called the back up physician rather then the program physician, on weekends, for verbal orders. The procedure had allegedly been changed, but the weekend nursing staff were not informed.
|
Plan of Correction
The program's nurse manager has informed all program nurses of the contact information for physician coverage during program operation hours when an NTP physician is not on-site, and the appropriate procedures for contacting the program physician and back-up physician when consultation and verbal orders appear to be needed. The nurse manager will review the dispensing nurses' documentation to insure that appropriate procedure is being followed. The program coordinator shall monitor compliance with the proper documentation of physician consultations and verbal orders via the quarterly review of client records, and will address any non-compliance via supervision sessions. |
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 the review of patient record documentation, the facility failed to ensure the physician document in the patient record the rationale for granting take home medication in three of five patient records.
The findings include:
Sixteen patient records were reviewed January 16-18, 2013. Five patient records were reviewed for take home medication documentation, specifically the physician's rationale for granting the take home medication. Patient records # 1, 2 and 14 did not have the physician's rationale for granting the take home medication.
|
Plan of Correction
Wording in the NTP's form used to document approval of take-home medication will be revised to clarify that the program physician needs to include a written rationale for each approval of take-homes when signing this form. The dispensing nurse shall insure that the physician's rationale is included on the form before the physician's take-home order is entered into the dispensing computer program. Program coordinator shall monitor compliance with the proper completion of take-home approval form via the quarterly review of client records, and will address any non-compliance via supervision sessions.
The medical director/program physician was informed of this requirement and is now documenting his rationale for granting take-homes on the designated form. |
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.
|
Observations
Based on the review of patient records, the facility granted take home privileges despite the patient not attending their counseling schedules as required or stated on the treatment plan for one of nine patient record.
The findings include:
Sixteen patient records were reviewed January 16-18, 2013. Nine patient records were reviewed for documentation of their take home medication status.
Patient # 2 was admitted August 24, 2011. The patient was being dosed on site 4 days weekly. The patient's treatment plan stated patient was to attend 1 weekly individual session and three group sessions. However, the patient was not attending all scheduled sessions, but was still receiving the take home privileges.
Patient # 3 was admitted July 25, 2003. The patient was dosing onsite once weekly, receiving six take home medication bottles each week. The patient's treatment plan stated the patient is to attend individual sessions once monthly. The patient failed to attend the scheduled sessions September, October, November and December, either not showing or cancelling. The patient continued to receive take home privileges.
Patient # 8 was admitted December 19, 2003. The patient currently receives six take home medication bottles per week, dosing onsite one time per week. The last documented progress note showing patient was attending sessions was dated October 19, 2012. The patient continued to receive take home privileges.
Patient # 11 was admitted June 8, 2011. The patient was dosing onsite three days weekly, receiving take home medication bottles the other four days. The patient started to not appear for his scheduled counseling appointments in June 2012. The pattern of missed counseling appointments continued every month until the end of October 2012. The patient continued to receive take home privileges and there was no explanation for the pattern of non attendance.
|
Plan of Correction
Program counselors have been re-instructed by the program coordinator to submit a Take-Home Medication Privilege Change Request form whenever a client fails to adhere to any of the stated eligibility criteria indicated on the form, including failure to comply with counseling session requirements, as well as documenting in the client's record any deviations from the treatment plan or other requirements. On at least a quarterly basis, the program coordinator shall review the roster of all program clients who are receiving take-homes and identify any clients who may not be meeting one or more of the eligibility requirements. The coordinator will then address the issue with the client's assigned counselor who will be held accountable for initiating the applicable appropriate action; e.g., requesting removal of take-homes or documenting an explanation for non-attendance, etc. The program coordinator shall monitor staff compliance with the proper submission of this form and appropriate documentation of any absences from counseling requirements via the quarterly review of client records, and will address any staff non-compliance via supervision sessions. |
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 the review of patient records, the facility failed to complete annual evaluations in accordance with the regulations in three of six patient records reviewed.
The findings included:
Sixteen patient records were reviewed on January 16-18, 2013. Six patient records were reviewed for annual evaluation of each patient's status.
Patient # 2 was admitted December 23, 2011. An annual evaluation was completed by the patient's counselor and dated August 16, 2012. It was not reviewed by the medical director until January 11, 2013.
Patient # 7 was admitted July 5, 2005. An annual evaluation was completed by the patient's counselor and dated June 25, 2012. It was not reviewed by the medical director until September 24, 2012.
Patient # 16 was admitted May 12, 2005. An annual evaluation was completed by the patient's counselor and dated April 20, 2012. However, it was identical to the annual evaluation completed and dated April 20, 2011. The counselor signed and dated it as 4/20/11. It was signed by the medical director and dated January 6, 2012.
|
Plan of Correction
The program coordinator shall develop a spreadsheet for tracking when annual evaluations are due for each individual client, including when they have been completed by the assigned primary counselor and when reviewed by the medical director. The program coordinator shall monitor staff compliance with the proper completion of annual evaluations via the spreadsheet and the quarterly review of client records, and will address any non-compliance via supervision sessions. The program coordinator has re-trained the program staff on the procedures and timing for the completion of annual evaluations, and informed them of the compliance monitoring procedures put in place. |