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 September 8, 9, 10 & 11, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health System Goldman Clinic 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 correction is due on October 27, 2008.
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Plan of Correction
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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of 34 patient records from September 9 through 11, 2008, in which 12 records were reviewed to determine facility compliance in the determination of one year history of addiction, the facility failed to document patient's one year history of addiction in 4 of 12 patient records where required.
Findings:
A review of patient records # 1, 24 and 34 revealed the physician had failed to provide documentation in the patient record that pertained to the patient's one year history of addiction. The narcotic treatment physician did not document in the patient 's record evidence of a 1 year history of addiction.
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Plan of Correction
Effective 10/27/2008, all newly admitted clients to the program will have their intake records reviewed by the administrative coordinator. The coordinator will assure the document which provides the documentation of one year addiction is present and completed. If this document is either absent or incomplete, the coordinator will immediately bring the document to the physician for completion. |
715.9(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
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Observations
Based on a review of 34 patient records from September 9 through 11, 2008, of which 6 patient records were reviewed to determine inclusion of documentation of prior treatment experiences in the patient record, the facility failed to contact the patient's former narcotic treatment program to request patient information in 3 of 6 patient records where required.
Findings:
Documentation in the patient records of patients # 4, 7, and 24 revealed these patients had received prior treatment in other narcotic treatment programs; there were no records of the prior treatment experiences nor documentation of attempts to obtain this information.
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Plan of Correction
Beginning 11/01/2008, the file room in the Goldman clinic will come under the supervision of the medical records department of the hospital. There will be a clerk assigned to the Goldman record room each day to assure filing is completed and no loose papers are left at the end of the day. Pt numbers 4, 7 and 24 documentation of prior treatment were located in the loose paper pile that needed to be filed. Oversight of this process will be the responsibility of the Director of Medical Records.
The clerk(s) assigned to the Goldman clinic will be trained by the Supervisor of Medical records regarding the proper filing and storage of the medical records at the Goldman clinic. This will be completed by 11/24/2008.
Written consent will be obtained from the client to submit a request to their prior program to obtain history. This consent will be obtained at the time of admission during the admission process. This is our current process. The program director will review this process with the supervisors, counselors and the admitting clerk to assure that this occurs during the admission process. This education will be completed and the process in place by January 15, 2009. This process has already begun. Counselors will monitor this process. When the first counseling session occurs, the counselor will review the medical record to assure the document is present and if it is not present, they will obtain the document at that time. |
715.10(b) LICENSURE Pregnant patients
(b) A narcotic treatment program shall give pregnant patients the opportunity for prenatal care either by the narcotic treatment program or by referral to appropriate health-care providers.
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Observations
Based on a review of 34 patient records from September 9 through 11, 2008, two were reviewed for content regarding treatment as a pregnant patient, the facility failed to document in two of two patient records where required that patients had pre-natal care or had been referred for pre-natal care.
Findings:
Following the review of patient records # 16 and 17, there was no documentation that revealed any knowledge or status of the patients' pre-natal care.
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Plan of Correction
Beginning 10/27/2008, the case managers in the Goldman Clinic will provide pre-natal educational information brochures along with contact information for pre-natal care at Jefferson University Hospital. They will provide documentation in the medical record that such information was provided. The case manager will communicate with the counselor to assure the type of support provided and the response of the client to that support will be documented in the treatment plan. The oversight of this process will be provided by the clinical supervisors as there will be 100% monitoring of all pregnant patients. This monitor and the results will become of part of the Performance Improvement Plan for the Goldman clinic. |
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 34 patient records, the records of two patient records were reviewed to determine compliance with pre-natal supports by the narcotic treatment program, the facility failed to document a treatment plan that addressed the patients pregnancy and needed supports in 2 of 2 patient records that were reviewed for content.
Findings:
There was no documentation of prenatal services in the treatment plans in patient records # 16 and 17.
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Plan of Correction
Beginning 10/27/2008, all case managers will be responsible for providing pre-natal support information via a brochure along with contact information for Jefferson University Hospital. The case managers will document their intervention along with the response to the intervention. They then will communicate with the client's counselor to assure this information is included in the treatment plan. The clinical supervisors will provide oversight as they have been instructed by the program director to monitor 100% of pregnant patients to assure the pre-natal support has been offered, validated by documentation along with documentation of the client's response and the plan for the future. They will also be responsible for assuring the treatment plans are updated as the client's condition progresses. |
715.14(a) 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.
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Observations
Based on a review of 34 patient records from September 9 through 11, 2008, of which 16 were reviewed for compliance with urinalysis testing, the facility failed to document urinalysis drug screen results in 5 patient records where required.
Findings:
Patient record # 2 contained no documentation of urinalysis results for June and August, 2008.
Patient record # 3 contained no documentation of urinalysis results for August, 2008.
Patient record # 7 contained no documentation of urinalysis results for August, 2008.
Patient record #14 contained no documentation of urinalysis results for August, 2008.
Patient record # 24 contained only the initial urinalysis drug screen that was completed on 6/30/08; there was no documentation of subsequent urine drug screens.
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Plan of Correction
Beginning 11/1/2008, medical records department of the hospital will take over the responsibilites of the file room at the Goldman Clinic. They will assure that all loose papers and lab results are filed in the client records by the end of each day. Urinalysis results for patients 2,3,7,14, and 24 were found in the loose paper file in the record room of the Goldman Clinic.
The administrative assistant will create a random U/A report in the AMS system on the first of each month. She will run the randomized report on the first of each month. The computer program will provide a randomized list of clients due for U/A for each day of the month. The administrative assistant will run the list each day of the month and print the list to assure urines are obtained on those clients for that day.
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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.
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Observations
Based on a review of 34 patient records, from September 9 through 11, 2008, of which 7 were reviewed for content that identified the physician's determination for take-home privileges, the facility failed to document the physician's rationalization for ordering take-home privileges in 7 of 7 patient records where required.
Findings:
The documentation in patient records # 5, 10, 11, 15, 22, 23 and 33 failed to include any documentation by the physician that included his rationale for ordering take-home privileges;
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Plan of Correction
Beginning 10/27/2008, the administrative assistant will pull and review the records of all clients with take home medications. She will check for the document which has the check off boxes with the 8 take home criteria. She will also check for the completion of that document, along with a rationale statement by the physician. If the document is absent or incomplete, she will have to check with the file room as it has been identifed that when charts are thinned, this document sometimes is removed. The document will either be replaced in the record or completed at that time. The program director has mandated that only progress notes will be removed when thinning a chart and only progress notes will become a part of the thinned chart.
The Program Director will review the importance of documenting the rationale regarding Standard 715.16(a)(3)-take home medications with the dispensing physician by 11/24/2008. Emphasis will be placed on the fact that the physician must do the documenting of his rationale for ordering the take home medications. |
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 on a review of 34 patient records from September 9 through 11, 2008, 7 patient records were reviewed for compliance with documentation pertaining to criteria for take-home privileges, generally referred to as the eight point criteria for take-home privileges. The facility failed to document a review that determined a patient met criteria for take-home privileges in 7 of 7 patient records where required.
Findings:
Patient records # 5, 10, 11, 15, 22, 23 and 33 failed to contain documentation that included the eight point criteria for take-home consideration. Documentation in the patient record referenced take-home privileges but the documentation did not cite the criteria used to determine these privileges.
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Plan of Correction
Beginning 10/27/2008, no take home medication will be dispensed without visualizing the form with the 8 criteria for take home medications. This review will be conducted by the dispensing physician and monitored by the administrative assistant.
The eight point criteria document for patients 5,10,11,15,22,23,and 33 were found in the thinned charts of the clients located in the Goldman record room. The program director has mandated that this form not ever be removed from the medical reoord when thinning a chart. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of 34 records from September 9 through 11, 2008, 18 patient records were reviewed for compliance with the requirements for the provision of psychotherapy services. The facility failed to provide each patient with the minimal requirement of an average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment. Psychotherapy was not provided as required in 4 of 15 patient records where required.
Findings:
Patient # 2 received 0 hours of psychotherapy in June, 2008, 3 hours in July, 2008 and 2 hours in August, 2008 for an average of 1.67 hours of psychotherapy a month.
Patient # 6 commenced treatment on June 26, 2008 and received 2.5 hours of psychotherapy in July, 2008, 1 hour in August, 2008 and 2 hours in September 2008 for an average 1.83 hours of psychotherapy a month.
Patient # 13 received 3 hours of psychotherapy in June, 2008, 2.5 hours in July, 2008 and 0 hours in August, 2008 for an average of 1.83 hours of psychotherapy a month.
Patient record # 26 contained no documentation of psychotherapy hours since 3/07/08.
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Plan of Correction
Beginning 10/1/2008, all counselors are now running groups for clients. As we offer more programming, all clients will be scheduled for at least one group per month. This will assure that all clients will receive at least 3 hours of therapy per month along with their individual therapy. The clinical supervisors will provide oversight as they will receive client names from group attendance sheets that verify they attended the group therapy. This process will begin 11/1/2008. |
715.20 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.
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Observations
Based on a review of facility policy and procedures on September 8, 2008, the facility failed to document a policy and procedure that was consistent with the standards regarding patient request for transfer.
Findings:
The facility stated in the policy and procedures regarding patient requests for transfer that a patient would be transferred when "the methadone project determines that the transfer is in the best interest of the client's health or safety". Pennsylvania code requires that the patient's request to be transferred is acted on within 7 days of the patient's request.
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Plan of Correction
The current policy will be changed by the Program Director by 11/15/2008. The change will delete that the project determines the transfer based on the best interest of the client. The policy will add that the patient's request will be acted on within 7 days. This change and need for the change was communicated to the employees on 10/21/2008 by the Program Director and Clinical Supervisors. |
715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on a review of 34 patient records from September 9 through 11, 2008, one was reviewed for compliance with the requirements to transfer patients. The facility failed to provide documentation of the information sent for the patient transferring to another facility.
Findings:
The transfer documentation for patient # 29 did not include a list of the information that was forwarded to the new treatment facility; documentation indicated a "transfer packet" was sent but did not specifically identify what was contained in the packet.
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Plan of Correction
On 10/20/2008, staff education of the current procedure regarding requirements for transfering a patient was completed by the Program Director for all employees. Information is faxed to the next provider. The fax cover sheet includes a list of documents that are included in the transfer packet. The fax cover sheet and confirmation then become a part of the medical record.
The supervisors will conduct 10 monthly chart audits beginning 11/24/2008 to assure the fax sheet and the confirmation sheet are in the medical record as proof of the contents of the list were forwarded to the new treatment facility. |
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 a review of the facility's policy and procedures on September 8, 2008, the facility failed to comply with the state regulations regarding patient termination for determining reasons to involuntarily terminate a patient from treatment.
Findings:
The facility's policy and procedure allows for the termination of patients for loitering near the facility, which is not one of the reason's listed in the policy and procedure.
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Plan of Correction
The Program Director has changed the existing policy and deleted the part that states the client can be terminated for loitering. The new policy will reflect the items listed in standard 715.21(1)(i-iv). This will be communicatd to all employees by the clinical supervisors and the new policy will be implemented by 11/15/2008. |
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 34 patient records from September 9 through 11, 2008, five patient records were required to have documentation of the annual physical examination performed by the physician. Documentation of the annual physical examination performed by the physician was missing in two of five patient records where required.
Finding:
There was no documentation of the annual physical examination in patient record #5. The physical examination was due on July 2008.
The annual physical examination was conducted by the physician's assistant, rather than the physician in patient record #32.
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Plan of Correction
Beginning 10/27/2008, the administrative assistant will review the names due for annual physicals each week. These are flagged in the AMS computer system. The physical form will come back to her before going to be filed. She will review the form to assure the physician has signed the physical and has written the diagnosis on the physical form. |
715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
Based on a review of 34 patient records from September 9 through 11, 2008, 10 patient records were reviewed for compliance with completed laboratory tests. Mantoux tests, as required, were not documented in 3 of 10 patient records where required.
Findings:
Mantoux tests for tuberculosis were not completed for patients # 14, 24 and 25.
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Plan of Correction
The Program Director has changed the procedure for Mantoux testing. All new clients will receive their Mantoux test on their first day by the nurse. A stop will be placed on all new clients so they cannot receive their first dose until the test has been read and documented. This was communicated to supervisors and counselors and nurses on 10/21/2008. This process will begin 11/1/2008. |
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 a review of 34 patient records from September 9 through 11, 2008, 16 were reviewed for treatment plan content. The facility failed to document complete treatment plans which provided for measurability within the goals and objectives and support services in 16 of 16 patient records where required..
Findings:
Sixteen patient records, specifically 1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 14, 15, 23, 24, 32 and 34 contained treatment plan goals that were not measurable. Further, the identified treatment plans did not include support services in any of the 16 records where required.
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Plan of Correction
As of 11/24/2008, all clinical supervisors will conduct staff training of all counselors regarding the books available in the Goldman clinic to be used as a resource when completing a treatment plan. Special attention will be emphasized in the training regarding writing measurable goals and objectives. Special attention will also be placed on documenting support services for the client. Each supervisor will review each counselors treatment plans each month. Any treatment plan that is unacceptable by the supervisor will be given back to the counselor to be re-written. This process has begun and will be a part of the ongoing Performance Improvement monitoring in the Goldman clinic. |
715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
Based on a review of facility policy and procedures, incident report logs, 34 patient records and staff interviews from September 8 through 11, 2008, the facility failed to follow the policy and procedure to address patient related incidents at this facility.
Findings:
Documentation consisted of policy statements without procedure. The missing procedure led to a failure by facility staff to report and respond to issues and incidents in a unified manner.
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Plan of Correction
The Program Director will revise the existing policy regarding unusual incidents. As per standard 715.28(a)(1-10), if any of these incidents occur, the supervisor will report the issue via e-mail to the program director within 48 hours. The Program Director will communicate with the supervisor as to how the incident will be addressed. This will occur within 7 days. The written communication along with documented follow up actions will be placed in the Unusual Incident Binder. All supervisors and counselors will be educated as to this new procedure and implementation will occur by 11/15/2008. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on a review of facility policy and procedures, incident report logs, 34 patient records and staff interviews from September 8 through 11, 2008, the facility failed to report incidents to the Department within 48 hours following the incident.
Findings:
Patient records # 29 and 32 documented incidents that should have been reported to the Department. Patient # 29 was discharged for selling drugs in proximity to the facility (28 Pa. Code Subsection 715.28(c)(4)) and patient # 32 was discharged for smoking cocaine in a facility bathroom (28 )Pa. Code Subsection 715.28(c)(4)).
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Plan of Correction
The Program Director will review the current policy to identify the 5 unusual incidents that require an unusual incident report form to be sent to the Department of Health within 48 hours as per standard 715.28(c)(1-5). The Program Director will provide staff training and review to the supervisors and counselors by 12/01/2008. The training will detail that when one of these 5 incidents occur, an unusual
incident report will be filed with the Department and a copy will be given to the Program Director. This correspondance will be placed in the unusual incident binder. This will begin on 12/1/2008. |