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 and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on June 25-28, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, North Philadelphia Health System 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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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of administrative documentation, the facility failed to provide at least one hour of physician time a week, on site for, every ten patients for four of the sixteen weeks reviewed.
The findings include:
Physician time sheets for the months of February, March, April, May and June were reviewed on June 26, 2013. Sixteen weeks were chosen and the staff was asked to provide the patient census for those seven weeks. Twelve weeks provided sufficient onsite physician hours for the patient census. Four weeks provided insufficient onsite physician hours during May and June.
During the week of May 19-25, 2013, the patient census was 688. The facility was required to provide at least 68.8 physician hours. There were 63.75 physician hours documented.
During the week of May 26 to June 1, 2013, the patient census was 685. The facility was required to provide at least 68.5 physician hours. There were 37.5 physician hours documented.
During the week of June 2-8, 2013, the patient census was 681. The facility was required to provide at least 68.1 physician hours. There were 56 physician hours documented.
During the week of June 9-15, 2013, the patient census was 681. The facility was required to provide at least 68.1 physician hours. There were 48 physician hours documented.
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Plan of Correction
1. The Medical Director will continue to monitor physician's schedules the first of each month to assure that all medical services and coverage are available to PIRs
2.Clinical coordinator will inform Director of physician scheduling conflicts that affect program coverage .
3.The Medical Director will provide physician coverage of 1 hour per week onsite for every ten PIRs in treatment . All addition, the physician assistant will assist the facility physicians by completing physical exams and or making referrals for PIRs.
4. All physician staffing time sheets will be maintained in a file as evidence and documentation that enough coverage is being provided to all PIRs. |
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 clinical documentation, the facility, particularly the physician, failed to accurately document the basis for determining current and one year history of dependency in two of ten patient records.
The findings include:
Twenty four patient records were reviewed June 25-28, 2013. Ten patient records were reviewed for physician documentation of the basis for determining current and one year history of dependency.
Patient # 1 was admitted April 25, 2013. The documentation by the physician for determining current dependency was based on the urine drug screen dated April 13, 2013 used by the facility that detoxified her. The patient was released from the facility that detoxified the patient on April 24, 2013. The admission urine drug screen was negative for opiates or any opiate derivative.
Patient # 2 was admitted May 28, 2013. The documentation by the physician for determining current dependency was based on the urine drug screen dated May 21, 2013 used by the facility that detoxified her. There was no documentation supporting the physician's justification for admitting the patient after the patient was detoxified.
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Plan of Correction
1.Physician will interview all PIRs to determine a one year history of opiate dependency,during intake process .
2.Physician will review assessments and other related histories to assist in determining a PIR's history of opiate dependency.
3.An exception will be requested, if a PIRs meets intake requirements, but has a cessation of opiate usage during their recent dependency history.
4.PIRs who doses not meet the exception requirements , the client will be informed by the Physician.
5.Physician will document justification in the Avatar system.
6.Physician will complete a state exeption request for approval to give a take home bottle to pir.
7. Medical Director & Program Director will monitor this process for ongoing compliance effective August 19, 2013.
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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 the review of patient records, the facility failed to contact the previous narcotic treatment facility for the patient's treatment history in two of two patient record reviewed.
The findings include:
Twenty four patient records were reviewed June 25-28, 2013. Two patient records required contacting the prior narcotic treatment facility for the previous treatment history the patient reported to have received.
Patient record # 1 contained documentation the patient had received narcotic treatment services previously at another narcotic treatment program. There was no documentation of an attempt to obtain the previous treatment history from the identified previous narcotic treatment program.
Patient record # 14 contained documentation the patient had received narcotic treatment services previously at another narcotic treatment program. There was no documentation of an attempt to obtain the previous treatment history from the identified previous narcotic treatment program.
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Plan of Correction
1.Director will perform a in-service on the importance obtaining PIRs treatment history in a timely manner to the intake staff on August 9,2013.
2.Clinic coordinator and intake worker will obtain PIR's written consent to request treatment history from previous narcotic facility.
3.Treatment history will be review upon receiving document from previous narcotic facility.
4.If treatment history is not received in a timely manner, clinical coordinator will continue outreach to PIR's previous narcotic facility.
5.The clinic coordinator will document in the chart attempts to gather information and inform supervisor of the ongoing issue(s).
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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, the facility failed to ensure at least monthly random urine drug screens for four of eighteen patient records reviewed.
The findings include:
Twenty four patient records were reviewed June 25-28, 2013. Eighteen patient records were reviewed for monthly urine drug screen results.
Patient # 5 was missing a urine drug screen for December 2012. Documentation demonstrated the patient was coming for treatment during this month.
Patient # 8 was missing a urine drug screen for February 2013. Documentation demonstrated the patient was coming for treatment during this month.
Patient # 13 was missing a urine drug screen for May 2013. Documentation to show whether the patient was coming for treatment during this month was not available for review.
Patient # 22 was missing a urine drug screen for April 2013. Documentation demonstrated the patient was coming for treatment during this month.
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Plan of Correction
1.Clinical supervisors will perform a in-service on the importance of monitoring urine results and evidents of UDS results documentation in chart on 8/19/2013.
2.Clinical supervisors will review (50) charts within sixty for compliance to policy 715.4 urine drug with a 100% benchmark. |
715.16(a)(1) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(1) A narcotic treatment program may give take-home medications only to a patient who the narcotic treatment physician has determined is responsible and able to handle narcotic drugs outside the narcotic treatment program.
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Observations
Based on the review of patient records and administrative documentation, the facility failed to ensure the physician made a determination patients were responsible and able to handle narcotic drugs outside the facility for six of six patients reviewed.
The findings include:
Twenty four patient records were reviewed June 25-28, 2013. Six patient records were reviewed for physician determination of the patient's responsibility and ability to handle narcotic drugs outside of the facility.
Patient # 1 was admitted April 25, 2013. The patient was given a take home bottle for the holiday May 27, 2013. There was no documentation of an exception order or justification by the physician for this take home bottle.
Patient # 3 was admitted April 3, 2013. The patient was given a take home bottle for the holiday May 27, 2013. There was no documentation of an exception order or justification by the physician for this take home bottle.
Patient # 4 was admitted February 13, 2013. The patient was given a take home bottle for the holiday May 27, 2013. There was no documentation of an exception order or justification by the physician for this take home bottle.
Patient # 8 was admitted January 8, 2013. The patient was given a take home bottle for the holiday May 27, 2013. There was no documentation of an exception order or justification by the physician for this take home bottle.
Patient # 21 was admitted April 25, 2013. The patient was given a take home bottle for the holiday May 27, 2013. There was no documentation of an exception order or justification by the physician for this take home bottle.
Patient # 22 was admitted September 12, 2012. The patient was given a take home bottle for the holiday May 27, 2013. There was no documentation of an exception order or justification by the physician for this take home bottle.
Administrative documentation in the electronic records of the patients reviewed showed the system automatically orders a take home bottle when the facility is closed six days annually for federal holidays.
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Plan of Correction
1.Counselors will present take home/reduced schedule form and obtain
Medical Director approval/disapproval.
3.PIRs who do not meet the criteria for exception during holidays will be assisted with the process of guest dosing at a facility near their residence.
4.Clinical supervisior will reveiw take home/reduced schedule policy and procudures during treatment team meeting Auguest 12, 2013.
5. Clinical supervisors will monitor for ongoing compliance on a weekly basis. |
715.20(4) 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.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on the review of patient records, the facility failed to document that it notified the referring facility of the admission and initial dosing of the patient in two of three patient records reviewed.
The findings include:
Twenty four patient records were reviewed June 25-28, 2013. Three patient records were reviewed for documentation of notification to the referring facility of the admission and dosing of the referred patient.
Patient records # 9 and 10 were referred by another narcotic treatment program and there was no documentation of the referral source being notified of the admission and initial dosing of the patients.
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Plan of Correction
1.Clinical supervisors will perform a inservice on PIR transfers Policy 715.20
on 8/19/2013 to reinforce important of notifing a facility of the admission and initial dosing of an PIR.
2.Director will perform a inservice with clinical supervisors about the process and importance of reviewing documentationao all transferred PIRs.
3.Clinical supervisors will review (25) charts each month for compliance to policy 715.20. |
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 the review of patient records and administrative documentation, the facility failed to restrict the reasons for involuntary termination to those reasons allowed by regulation.
The findings include:
Twenty four patient records and the binders containing unusual incidents, grievances and appeals were reviewed June 25-28, 2013. Four patient records were reviewed for involuntary, or therapeutic, discharge.
Patient # 18 was involuntarily terminated April 22, 2013. The documentation presented the patient was terminated for not attending counseling sessions. The documentation reviewed demonstrated the patient was coming to the facility daily to dose.
Patient # 20 was involuntarily terminated April 9, 2013. The documentation presented the patient was terminated for not attending counseling sessions. The documentation reviewed
demonstrated the patient was coming to the facility almost daily to dose.
The documentation of letters of termination and appeals was reviewed June 25, 2013. The following patients had received notice of termination for their lack of attendance for clinical services. The appeals were granted but the notice stated if they violated the contract, they would be immediately terminated. These patients are # 25, 26, 27, 28 and 29.
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Plan of Correction
1.Behavorial staff will utilizes all therapeutic tools to motivate PIR participation i.e. holds, contracts, case conference with PIR to prevent involuntarily terminations due
2.Clinical supervisor will provide a in-service on regulation 715.21(1)i-iv on 8/26/2013 during treatment team meeting.
3.Clinical supervisors will review terminations for 100% compliance to 715.21(1)i-iv. |
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 the review of patient records, the facility failed to complete the annual physical with a re-evaluation by the physician in four of eight patient records reviewed.
The findings include:
Twenty four patient records were reviewed June 25-28, 2013. Eight patient records were reviewed specifically for documentation of an annual physical exam with a re-evaluation by the physician.
Patient # 13 was admitted May 5, 2011. An annual physical was to have been completed by May 5, 2013. There was no annual physical with a re-evaluation by the physician at the time of the inspection.
Patient # 14 was admitted March 30, 2012. An annual physical was to have been completed by March 20, 2013. There was no documentation of annual physical with a re-evaluation by the physician at the time of the inspection.
Patient # 15 was admitted December 10, 1999. An annual physical was completed by the Certified Physician's Assistant (PAc) January 15, 2013. The PAc completed the re-evaluation of continuing medication assisted treatment with a reduction in dose of 2 milligrams per week until 0 milligrams. The narcotic treatment physician is required by regulation to make the medication determination.
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Plan of Correction
1.Medical Director will perform a annual physicial policy and procedures in-service during general staff meeting on August 19,2013.
2. Physician assitant will check Avatar's care plans and complie a list of the upcoming month's PIRs due for annual physical and revaluations.
3.A message will be placed in Avatar as a reminder to the PIR and staff of the physical due date.
4.PIRs will be placed on hold ,if physical due date is missed to assure the next appointment is attended.
5.The Medical Director will review ,sign and completed annual physicals and re-evaluations.
6.Clinical coordinator will file physicals and re-evualations
7.Clinical supervisor will reviews PIR's charts and will immediately notify Medical Director of missing annual physical exams or re-evaluations.
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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 the review of patient records, the facility failed to complete all required laboratory tests as part of the admission process in nine of nine patient records reviewed.
The findings include:
Twenty four patient records were reviewed June 25-28, 2013. Nine patient records were reviewed for completed laboratory tests as part of the admission process, specifically a tuberculosis Mantoux test (PPD). Nine patient records had no PPD completed as part of the admission process.
Patient records # 1, 2, 4, 8, 9, 10, 20, 21 and 24 did not have documentation of tuberculin Mantoux test having been administered as part of the admission process.
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Plan of Correction
Currently, the LPN's do a PPD test on all admissions. This documentation is kept in a binder in the medication administration area. The nurse who admits/ read PPD to the client will assure the original PPD documentation goes to the client's counselor to be placed in the medical record after the PPD is read. A copy will remain in the binder in the medication administration area/nurses station.
This will be monitored by the Clinical Director of Nursing for the Goldman Clinic. She will be monitor this by completing random chart checks to assure the process is working. This monitoring will be a part of the nursing performance improvement plan for this department. These results will be reported quarterly to the Nursing PI Committee.
All nurses will be in serviced on this new process. This started as of August 15, 2013.
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715.23(b)(22) LICENSURE Patient records
(b) Each patient file shall include the following information:
(22) Aftercare plan, if applicable.
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Observations
Based on the review of patient records, the facility failed to include an aftercare plan as required in two of three patient records reviewed.
The findings include:
Twenty four patient records were reviewed June 25-28, 2013. Three patient records were reviewed for completed aftercare plans. Two of the three required an aftercare plan.
Patient # 15 was discharged March 15, 2013 as having completed treatment. A document entitled "Aftercare Plan" was signed by the patient and counselor on February 28, 2013. However, there were no goals or time frames identified, only problem areas needing to be addressed.
Patient # 17 was discharged as having completed treatment April 2, 2013. A document entitled "Aftercare Plan" was developed by the counselor on April 9, 2013, a week after the patient was discharged. There were no goals or time frames identified, only problem areas needing to be addressed.
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Plan of Correction
1.Clinical supervisors will perform a in-service on policy 711.94(d)on 8/02/2013 during treatment team.
2.Clinical supervisors will review and monitor counselors ability develop goals and time frames.
3.Counselors will be schedule for aftercare planning training,if it is area in need of improvement.
4.Clinical supervisors will review possible 30 plus charts within sixty days for compliance to policy 711.94(d) |