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 September 11-12, 2008 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 correction is due on October 8, 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 patient records on September 12, 2008, the facility failed to document current dependency and one year history of dependency in two of seven patient records where required.
Finding:
The facility physician did not complete the documentation of addiction form in patient records #7 and 11.
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Plan of Correction
In order to maintain continued compliance with this standard the physician staff will be notified of the deficiency and made aware of the importance of completion of the documentation of addiction. To ensure continued compliance all intake documentation including the documentation of addiction will be reviewed prior to admission to the program. |
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 patient records on September 12, 2008, the facility failed to document they contacted the previous narcotic treatment facility for the treatment history in one of two patient records where required.
Finding:
The facility did not document they contacted the previous narcotic treatment facility for the treatment history in patient record #11.
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Plan of Correction
The supervisory team will determine the appropriate means to document refused attempts to obtain previous narcotic treatment. The project director will then provide instruction to the staff so that we may obtain compliance with this standard. |
715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
Based on a review of patient records on September 12, 2008, the facility failed to obtain a release of information to disclose information in a patient transfer in two of four patient records where required.
Finding:
The facility disclosed information to a transferring facility without the patient's consent to release information in patient records #5 and 10.
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Plan of Correction
The project director will provide a training on confidentiality and the proper utilization of the current releases of information. A review of current documentation trails will also be conducted by the project director to determine any deficiencies in filing accuracy. Chart audits will then be conducted to ensure compliance with this regulation. |
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 the patient records on September 12, 2008, the facility failed to document a monthly urinalysis test for one of nine patient records where required.
Finding:
The facility did not document a monthly urinalysis for March 2008 and May 2008 in patient
record #11.
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Plan of Correction
To ensure future compliance all staff will meet with the project director and the staff will be instructed to document reciept of all urines for clients on each of their caseloads and one week prior to the end of the month each staff member will turn in a list of individual clients for whom they did not recieve urinalysis results to the nursing staff. The nursing staff will then schedule any clients who are not scheduled for urines. |
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 the patient records on September 12, 2008, the facility failed to document the rationale for granting take home medication in one of six patient records where required.
Finding:
The facility physician did not document the rationale for granting take home medication in patient record #11. The patient was granted weekend takehomes, yet did not have monthly urinalysis testing documented. Therefore, the physician could not have been able to determine eligibility.
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Plan of Correction
The project director will instruct the clinical staff that if a random monthly urinalysis was not obtained in any given month that this must be considered in the determination of the appropriateness for submission of the take-home privilege request form to the physician for approval. |
715.16(a)(4) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(4) A narcotic treatment physician may rescind take-home medication privileges.
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Observations
Based on a review of patient records on September 12, 2008, the facility failed to document the revocation of take home privileges in one of six patient records where required.
Finding:
The facility physician did not document the revocation of take home privileges in patient record #3.
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Plan of Correction
The physician and medical staff will be informed by the project director of the deficiency and the clinical staff will be instructed to review all documentation proir to filing it in the clinical chart for completeness. Chart audits will then be performed to ensure continued compliance with this regulation. |
715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on a review of the patient records on September 12, 2008, the facility failed to document that the physician made the dose changes in four of six patient records where required.
Finding:
The facility did not document that the physician made the dose changes. There was no evidence of who authorized the changes in patient medication doses in patient records # 6, 7, 8 and 11. The facility has a "dose adjustment/physician order" form that is competed by staff other than the physician. The nurse documented the dose increases and decreases and the physician circled "approve" or "disapprove" and signed the order.
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Plan of Correction
The dosage adjustment form will be reviewed by the project director and medical director to determine how we will be able to more efficiently document dosage adjustments made by the physician staff and the form will be adjusted accordingly. The new form will then be reviewed with all staff and instructions will be provided to ensure proper use of the form and continued compliance with the regulation. |
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 all of the patient records on September 12, 2008, the facility failed to ensure that patients were not discharged for reasons other than those listed for involuntary terminations.
Finding:
All of the patient records reviewed included a Financial Responsibility form that states, "Payments must be made by Wednesday of the current week or client may be discharged from the program." Record # 7 included a signed Notice of Failure to follow the treatment plan goals form. On the form it states, "By signing this agreement, I understand that failure to keep this payment arrangement could result in a 7 day involuntary detox." This form was signed on the day of admission, prior to completion of the treatment plan. Facilities may not financially detox patients.
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Plan of Correction
The financial responsibility form and Failure to follow treatment plan goals notification will be reviewed and updated by the project director and the statements noted will be removed. |
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 patient records on September 12, 2008, the facility failed to document the results of the laboratory tests in four of eight records where required.
Finding:
The facility failed to document the TB testing in patient records # 1 and 11. Blood work results were not documented in patient record #5 and were five months late in patient record #7.
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Plan of Correction
The project director will provide training with the nursing staff where a review of the bloodwork and TB policies and procedures will be conducted. The counselors will then be instructed to review all documentation of any new clients to ensure that all intake documentation has been completed and is correct including reciept of bloodwork and reading of TB test performed
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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.
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Observations
Based on a review of the patient records on September 12, 2008, the facility failed to have the medical director sign the annual evaluation in two of two patient records where required.
Finding:
The facility documented the narcotic treatment physicians signature on the annual clinical evaluation, but was lacking the medical directors signature in patient records # 3 and 4.
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Plan of Correction
The project director will instruct all clinical staff that all annual evaluations are to be reviewed and signed by the medical director and not the attending physicians. The medical director will also be informed that all annual evaluations are to be reviewed an signed by the medical director. To ensure continued compliance chart audits will be performed to review the annual evaluations for the medical directors signature. |