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 January 15, 2014, through January 16, 2014, by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the findings of the on-site inspection, Kensington Hospital 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(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 the review of patient records, the narcotic treatment program failed to document a narcotic treatment physician made a face-to-face determination of current dependency in one of nine records.
The findings included:
Nine patient records were reviewed during the onsite monitoring visit. All records were reviewed for the narcotic treatment physician's face-to-face determination of current dependency. The facility failed to document a narcotic treatment physician made a face-to-face determination in patient record # 5.
Patient # 5 was admitted into treatment on May 7, 2013, and received a narcotic agent. The physical exam and the documentation of physical dependency were completed by the Certified Registered Nurse Practitioner (CRNP) on May 7, 2013. Additionally, the physician documentation of addiction was signed by the physician, however, dated by the CRNP.
The findings were reviewed and confirmed with the Facility Director.
This is a repeat deficiency from the January 16, 2013 on-site monitoring visit.
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Plan of Correction
Our policy states the Narcotic Treatment Physician must have a face to face encounter with the client to determine eligibility for admission to the Program. This eligibility will determine if the individual is currently psysiologically depended upon a narcotic drug and has been psysiologically dependent for at least one (1) year for admission to MAT. The Narcotic Treatment Physician will document the basis of the above. In order to assure continued compliance our Performance Improvement Coordinator will review 10% of new admissions for two (2) quarterly basis (March 2014 - August 2014) and document findings and present those findings to the Performance Improvement Committee. The Narcotic Treatment Physician will be notified of the audit. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
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Observations
Based on the review of patient records, the narcotic treatment program failed to obtain an informed, voluntary, written consent prior to the administration of a narcotic agent in one of nine records.
The findings included:
Nine patient records were reviewed during the onsite monitoring visit. All records were reviewed for obtaining an informed, voluntary, written consent prior to the administration of a narcotic agent. The narcotic treatment program failed to document an informed, voluntary, written consent was obtained prior to the administration of a narcotic agent in record # 6.
Patient # 6 was admitted into treatment on July 17, 2013. The patient received their initial dose of a narcotic agent on July 18, 2013. There was no documentation of an informed, voluntary, written consent prior to the administration of a narcotic agent in the record at the time of the review. Patient # 6 was discharged on July 22, 2013.
The findings were reviewed with the Director of Nursing and confirmed.
This is a repeat deficiency from the January 16, 2013 on-site monitoring visit.
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Plan of Correction
No patient admitted will receive methadone or detox treatment without a voluntary written consent signed by the patient. An in-service will be given to admitting staff during the first week in March 2014 regarding instructions for written consent. The Nursing staff will be instructed by the Director of Nursing to insure that prior to admission and treatment that the consent form is properly executed. The Nursing Director will randomly review charts on a monthly basis for next three (3) months to assure future compliance. The consent does contain items (1) through (5). |
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 the review of patient records and administrative documents, the narcotic treatment program failed to obtain a complete drug screen urinalysis prior to the administration of a narcotic agent in nine of nine patient records.
The findings included:
Nine patient records were reviewed during the onsite monitoring visit. All records were reviewed for a complete drug screen urinalysis prior to the administration of a narcotic agent.
The onsite laboratory permit was reviewed. The permit included providing dipstick urinalysis. The collected specimen is then sent to an offsite laboratory.
The narcotic treatment program did not receive the completed drug-screening urinalysis prior to administration of a narcotic agent in nine of nine patient records.
Patient # 1 was admitted into treatment and received a narcotic agent on October 2, 2013. The initial drug-screening urinalysis results were received and reviewed by the narcotic treatment physician on October 3, 2013.
Patient # 3 was admitted into treatment and received a narcotic agent on October 16, 2013. The initial drug-screening urinalysis results were received and reviewed by the narcotic treatment physician on October 17, 2013.
Patient # 4 was admitted into treatment and received a narcotic agent on January 13, 2014. The initial drug-screening urinalysis results were received and reviewed by the narcotic treatment physician on January 14, 2013.
Patient # 5 was admitted into treatment and received a narcotic agent on May 7, 2013. The initial drug-screening urinalysis results were received and reviewed by the narcotic treatment physician on May 8, 2013.
Patient # 6 was admitted into treatment and received a narcotic agent on July 17, 2013. The initial drug-screening urinalysis results were received and reviewed by the narcotic treatment physician on July 18, 2013.
Patient # 7 was admitted into treatment and received a narcotic agent on July 23, 2013. The initial drug-screening urinalysis results were received and reviewed by the narcotic treatment physician on July 24, 2013.
Patient # 8 was admitted into treatment and received a narcotic agent on September 27, 2013. The initial drug-screening urinalysis results were received and reviewed by the narcotic treatment physician on September 28, 2013.
Patient # 9 was admitted into treatment and received a narcotic agent on January 13, 2014. The initial drug-screening urinalysis results were received and reviewed by the narcotic treatment physician on January 14, 2014.
Patient # 10 was admitted into treatment and received a narcotic agent on January 11, 2014. The initial drug-screening urinalysis results were received and reviewed by the narcotic treatment physician on January 13, 2014.
The findings were reviewed and confirmed by the Project Director, Facility Director and Medical Director.
This is a repeat deficiency from the January 16, 2013 on-site monitoring visit.
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Plan of Correction
The Hospital has arranged with our Laboratory to have an additional pick up for urine drug screens and to process them on a STAT basis. No patient will be admitted until the results of the UDS is faxed to the Hospital. This process went into effect 2/14/14. The Director of Nursing instructed the Nursing Staff that no patient is to have medication administered without a full UDS result. The Director of Nursing will monitor the admissions on a daily basis for 30 days to assure compliance. |
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 narcotic treatment program failed to document the consultation between the narcotic treatment physician determining the initial dose and the physician performing the physical examination in one of nine records.
The findings included:
Nine patient records were reviewed during the onsite monitoring visit. All records were reviewed for the narcotic treatment physician physical exam and initial dose. The facility failed to document a narcotic treatment physician consultation with the physician completing the physical examination in patient record # 5.
Patient # 5 was admitted into treatment on May 7, 2013, and received a narcotic agent. The patient was discharged on May 13, 2013. The physical exam, diagnosis and the documentation of physical dependency were completed by the Certified Registered Nurse Practitioner (CRNP) on May 7, 2013. The physical exam was signed by the narcotic treatment physician on May 18, 2013, 11 days following the patient's admission into treatment and five days after discharge. A consultation with the CRNP was not documented by the narcotic treatment physician prior to documenting an order for the initial dose.
The findings were reviewed with the Project Director, Facility Director and Medical Director and confirmed.
This is a repeat deficiency from the January 16, 2013 on-site monitoring visit.
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Plan of Correction
The CRNP no longer performs the history and physical for behavioral health services. The physician conducting the history and physical determines the initial dose for the patient.
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715.21 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.
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Observations
Based on a review of the policy and procedures, the narcotic treatment program failed to develop a termination policy that was limited to the areas set by regulation.
The findings included:
The policies and procedures were reviewed during the onsite monitoring visit.
The narcotic treatment program termination policy identified patients can be discharged for sexual activity, shouting from windows, going into a room without authorization, smoking in bed, use/possession of a cell phone, stealing and not mentioning a drug transaction. The reasons identified within the policy exceed those permitted by regulation.
The findings were reviewed with the facility director and confirmed.
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Plan of Correction
The Policy & Procedure will be changed to reflect appropriate reasons permitted by regulations. The Director of Behavioral Health Services will review all involuntary terminations to insure future compliance. |
715.22(a) LICENSURE Patient grievance procedures
(a) A narcotic treatment program shall develop and utilize a patient grievance procedure.
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Observations
Based on a review of the policy and procedures, the narcotic treatment program failed to develop a patient grievance procedure that met the level of care.
The findings included:
The policies and procedures were reviewed during the onsite monitoring visit.
The narcotic treatment program grievance procedure stated patients submitting a grievance can expect to receive a formal response within 2 days and within 10 days a meeting would be scheduled to review the grievance. This is a detoxification level of care with less than 10 days of treatment. The time in treatment does not coincide with the duration of the grievance process.
The findings were reviewed with the facility director and confirmed.
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Plan of Correction
A meeting was held on 1-28-14 to review the changes that were found to be necessary to make our grievance process more practical in the timeframes that were discussed during the monitoring visit of 1-15,16-14. The biggest change made was the timeframe that the grievance would be read, processed and responded to. It would be more practical and credible to state that the maximum for responding to a grievance would be 24
hours. If the person filing the grievance is not satisfied with the result, they could contact CBH and re-file their complaint with the consumer advocate at CBH. It will be the responsibility of the Director to review and respond to grievances in a fair and impartial manner. These changes went into effect on 1-28-14. |
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, the narcotic treatment program failed to include a psychosocial evaluation in three of nine records.
The findings included:
Nine patient records were reviewed during the onsite monitoring visit. All records were reviewed for the inclusion of a psychosocial evaluation. The narcotic treatment program failed to document a psychosocial evaluation in patient records # 4, 9 and 10.
Patient # 4 was admitted into treatment on January 13, 2014. A psychosocial evaluation was not documented at the time of the review.
Patient # 9 was admitted into treatment on January 13, 2014. A psychosocial evaluation was not documented at the time of the review.
Patient # 10 was admitted into treatment on January 11, 2014. A psychosocial evaluation was not documented at the time of the review.
The findings were reviewed and confirmed by the facility director.
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Plan of Correction
Every patient admitted will receive a psychosocial evaluation within 24 hours of admission by a credentialed counselor. The Nursing Supervisor in their 24 hour chart review will add this task to their checklist.
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