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 July 18-19, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Soar Corporation Chester 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.
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Plan of Correction
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715.9(e) LICENSURE Intake
(e) A narcotic treatment program shall secure a personal history from the patient within the first week of admission. The personal history shall be made a part of the patient record.
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Observations
Based on the review of patient records and discussion with the clinical supervisor, the facility failed to secure a personal history from the patient within the first week of admission in three of four patient records.
The findings include:
Twelve patient records were reviewed July 18-19, 2011. Four records were reviewed for documentation of the personal history that was to be secured within the first week of treatment. Patient records # 3, 4 and 8 did not have the personal history secured within the first week of admission.
Patient # 3 was admitted June 24, 2011. The personal history was documented and dated July 8, 2011.
Patient # 4 was admitted June 3, 2011. The personal history was documented and dated July 1, 2011.
Patient # 8 was admitted May 2, 2011. The personal history was documented and dated June 1, 2011.
The finding was discussed with the clinical supervisor who agreed the intake assessor only documented the first three pages of the psychosocial history during the intake and the assigned counselor completed the remaining personal history within 30 days of the patient's admission.
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Plan of Correction
Project Director will issue memo to all clinical staff with time frames required for personal history to be done in. Program Manager will monitor for compliance through supervision and chart audits. Program Manager will perform inservice training regarding proper way to document personal histories of those admitted to Soar.
Inservice to be done in Chester by 9/30/2011. Memo already given to all clinical staff of both programs. |
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 the review of patient records and a discussion with administrative staff, the facility failed to demonstrate the physician made the determination of the patient's dose in 2 of 5 patient records.
The findings include:
Twelve patient records were reviewed July 18-19, 2011. Five patient records were reviewed for physician's documentation of the patient's initial dose and schedule. Two of the five patient's were new to the methadone program and needed to be inducted onto methadone.
Patient # 1 was admitted to the facility July 15, 2011. The physician wrote a standing order for patient to be inducted starting with 30 mg on July 15, 2011, 40 mg on July 16, 2011, 50 mg on July 17, 2011 and 60 mg on July 18, 2011.
Patient # 3 was admitted to the facility June 24, 2011. The physician wrote a standing order for patient to be inducted starting with 25 mg on June 24, 2011, 30 mg on June 25, 2011, 35 mg on June 26, 2011, 40 mg on June 27, 2011, 45 mg on June 28, 2011 and 50 mg on June 29, 2011.
A review of patient records # 1 and 3 revealed that there was no documentation by the admitting physician that addressed the rationale for an increase of 10 mg of methadone daily.
On September 4, 2007, all narcotic treatment programs were issued a letter regarding methadone dose orders, especially during the induction phase, by the Department of Health & Human Services, Substance Abuse and Mental Health Services Administration: (SAMHSA)
In part, the following is excerpted from the letter:
"Because methadone overdose deaths have occurred in early treatment due to the drug's
cumulative effects of the first several days, it is also important to be cautious when
adjusting the dose. According to the drug labeling, the peak respiratory depressant
effects of methadone typically occur later and persist longer than its peak analgesic effects, which can contribute to cases of iatrogenic overdose, particularly during treatment initiation and dose titration. With repeated dosing, "methadone may be retained in the liver and released slowly, prolonging the duration of action despite low plasma concentrations." The drug labeling also states that "steady-state concentrations are not usually attained until 3 to 5 days of dosing," and that doses "will 'hold' for a longer period of time as tissue stores of methadone accumulate." Therefore, patients should be closely monitored during the induction phase, and the increase in dose should be under the close supervision of a physician as stated in 42 CFR 8.12 (h)(4), ' Dosing and administration decisions shall be made by a program physician familiar with the most up-to-date product labeling'. "
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Plan of Correction
Program Director will meet with Medical Director and other Soar doctors in mini-training regarding all new pts requuired to be seen on regular basis while being titrated to stable dose. All will be informed that standing orders can no longer be done. Program manager will monitor for compliance during chart audits. |
715.18(a)(1) LICENSURE Rehabilitative services
(a) A narcotic treatment program shall provide, either onsite or through referral agreements, a full range of rehabilitative services. Rehabilitative services shall include:
(1) HIV education services.
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Observations
Based on a review of administrative documentation and patient records, the facility failed to provide HIV education services either through referral or onsite.
The findings include:
Twelve patient records were reviewed July 18-19, 2011. The policy and procedure manual was reviewed July 18, 2011. The policy and procedure manual included a section that held the facility's referral agreements. There was no signed referral agreement for HIV education services in the manual. The facility director also looked for the signed agreement and was unable to locate it. There were no referrals documented within the patient records reviewed. There was no documentation of HIV prevention education within the patient records reviewed.
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Plan of Correction
Program Manager will contact local agencies to establish referral agreements with support services as identified by DAPL. Referral agreements from Soar will be sent to local agencies by Program Director.
This will be done on an annual basis. Project Director will monitor for compliance on annual basis. |
717.18(a)(2) LICENSURE Rehabilitative services
(a) A narcotic treatment program shall provide, either onsite or through referral agreements, a full range of rehabilitative services. Rehabilitative services shall include:
(2) Employment services.
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Observations
Based on a review of administrative documentation and patient records, the facility failed to provide employment services through referral or onsite.
The findings include:
Twelve patient records were reviewed July 18-19, 2011. The policy and procedure manual was reviewed July 18, 2011. The policy and procedure manual included a section that held the facility's referral agreements. There was no signed referral agreement for employment services in the manual. The facility director also looked for the signed agreement and was unable to locate it. There were no referrals for employment services documented within the patient records reviewed.
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Plan of Correction
Program Manager will contact local agencies to establish relationship for employment services to be provided. Project Director will monitor for compiance in supervision |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on the review of patient records and administrative documentation, the facility failed to ensure the psychosocial evaluations were a clinical assessment of the historical data collected in four of four patient records.
The findings include:
Twelve patient records were reviewed July 18-19, 2011. Four patient records were reviewed for psychosocial evaluations.
Patient # 2 was admitted June 13, 2011. The psychosocial evaluation was a document that contained a repeat of the data or listed comments without a clinical assessment of the collected historical data.
Patient # 3 was admitted June 24, 2011. The psychosocial evaluation was not documented in the patient file at the time of the review.
Patient # 4 was admitted June 3, 2011. The psychosocial evaluation was a document that contained a repeat of the data or listed comments without a clinical assessment of the collected historical data.
Patient # 8 was admitted May 2, 2011. The psychosocial evaluation was not documented in the patient file at the time of the review.
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Plan of Correction
Program Manager will provide inservice training to all clinical staff on proper way to do psychsocial. Same will monitor through chart audits and supervision throughout the year. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on a review of patient records, the facility failed to document all of the required information in four of four patient records.
The findings include:
Twelve patient records were reviewed July 18-19, 2011. Four patient records were reviewed for complete discharge summaries.
Patient # 8 was admitted May 2, 2011 and discharged July 10, 2011. The discharge summary was documented, but the summary did not include the services offered or the status of the patient upon discharge.
Patient # 9 was admitted February 8, 2011 and discharged May 11, 2011. The discharge summary was documented, but the summary did not include the services offered or the status of the patient upon discharge.
Patient # 10 was admitted November 23, 2010 and discharged May 11, 2011. The discharge summary was documented, but the summary did not include the services offered or the status of the patient upon discharge.
Patient # 11 was admitted January 4, 2011 and discharged June 24, 2011. The discharge summary was documented, but the summary did not include the services offered or the status of the patient upon discharge.
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Plan of Correction
Program manager will change form to include specifically the services offered and the status of patient upon discharge. Project Director willmonitor for compliance. Program Manager will perform inservice training for all clinical staff regarding proper way to do a discharge summary. |