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 October 15-17, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Addiction Medicine and Health Advocate 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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715.7(a)(1-2) LICENSURE Dispensing or administering staffing
(a) A narcotic treatment program shall be staffed as follows:
(1) If it operates an automated dispensing system, one full-time nurse or other person authorized by law to administer or dispense a controlled substance shall be available for every 200 patients.
(2) If it operates a manual or nonautomatic dispensing system, one full-time nurse or other person authorized by law to administer or dispense a controlled substance shall be available for every 150 patients.
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Observations
Based on a review of administrative documentation, observation and discussion with staff, the facility failed to ensure one full time person for every 200 patients.
The findings include:
Administrative documentation that included the Narcotic Treatment Program Monitoring Questionnaire completed by the clinical director prior to the monitoring inspection, was reviewed October 15, 2012. The questionnaire included documentation of the nursing staff and designation of full or part-time status as a means to identify that sufficient nursing hours are provided by the facility for the purpose of dispensing medication. The nursing supervisor was listed as spending 25 hours per week medicating patients. Another nurse was listed as a full time medication nurse. A third nurse was listed as being full time dispensing, but this nurse also has other program duties that take up at least half her working hours at the facility. Through documentation and staff reporting, the facility had one full-time nurse and two part-time nurses to provide medication dispensing to the 493 patients.
Observation of the dispensing process was completed on October 17, 2012 between 11:00 and 12:15 PM. It was observed that one dispensing nurse was medicating the patients because a patient presented and needed to be seen for a medical concern in a private area by the second dispensing nurse. Once this dispensing nurser returned the other other had to shut down her window to address other necessary functions.
The facility is required to have two and one half full time dispensing staff for 500 patients. Through means of facility documentation observation, the facility did not provide sufficient coverage for dispensing.
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Plan of Correction
AMHA will provide the required dispensing staff by having available three full time nurses and four part-time/on-call nurses to serve the 500 patients. The nurses will be deployed so that there is always sufficient coverage at the dispensing station. The clinical coordinator and the nursing supervisor will be responsible for assuring the required amount of dispensing time and coverage is consistent with 715.7(a)(1-2)at all times. |
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 discussion with facility staff, the facility failed to ensure at least monthly random urine drug screens for two of ten patient records.
The findings include:
Seventeen patient records were reviewed October 15-17, 2012. Ten patient records were specifically reviewed for monthly urine drug screen results.
Patient # 2 was admitted May 2012. There was no documentation of a urine drug screen completed for the month of August 2012.
Patient # 17 was admitted September 2011. There was no documentation of a urine drug screen for the month of July 2012. This patient was discharged in September 2012.
Reported the information to the clinical coordinator, who stated that monthly urine drug screens are sometimes missed.
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Plan of Correction
The clinical coordinator will educate the intake nurse about the importance of making certain that all new patients are scheduled for an intake urine on the day of admission. The nurse will also be educated regarding the requirement for at least one monthly urine screen being completed for all patients. The clinical coordinator with discuss with the computer software company the importance of the system scheduling all patients according to the requirements noted in 715.14(a) of the regulations. The nursing supervisor will be responsible for monitoring the scheduling and completion of urine screens for each patient each month. The process will also be monitored each month during the regular Performance Improvement committee meeting. |
715.23(b)(14) LICENSURE Patient records
(b) Each patient file shall include the following information:
(14) Case consultation notes regarding the patient.
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Observations
Based on the review of patient records, the facility failed to complete case consultations as required in four of twelve patient records reviewed.
The findings include:
Seventeen patient records were reviewed October 15-17, 2012. Twelve patient records were reviewed for case consultations.
Patient # 2 was admitted May 25, 2012. There was no case consultation documented in the patient record at the time of the monitoring.
Patient # 5 was admitted August 21, 2007. There must be a case consultation at least annually after the first year in treatment. The last case consultation documented was dated August 19, 2011.
Patient # 6 was admitted October 10, 2003. There was an annual case consultation that listed the counselor and a staff person who left the agency over one year ago as the other party involved in the case consultation.
Patient # 8 was admitted March 20, 2012. There were no case consultations in the patient record, though two should have been completed at the time of the monitoring.
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Plan of Correction
A group supervision meeting will be conducted to reinforce the importance of case consultations being completed annually for patients enrolled on the clinic for more that one year, and every 90 days for those patients enrolled less than one year. The supervision meeting will also address the correct completion of the case conference to include current multidisciplinary staff: administrative, medical and clinical. The clinical coordinator and clinical supervisor will monitor and assure compliance during individual staff supervision. Compliance will also be monitored during quality record reviews and monthly Performance Improvement committee meetings. |
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 the review of patient records, the facility failed to complete annual evaluations in accordance with the regulations in three of seven patient records reviewed.
The findings included:
Seventeen patient records were reviewed October 15-17, 2012. Seven patient records required documentation of an annual clinical review.
Patient # 4 was admitted May 18, 2005. An annual evaluation was due in May 2012. The annual evaluation was not completed until July 2, 2012.
Patient # 5 was admitted August 21, 2007. The last documented annual evaluation was dated August 19, 2011.
Patient # 14 was admitted August 17, 2011. An annual evaluation was not completed in August 2012, prior to the patient's September discharge.
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Plan of Correction
A group supervision meeting will be conducted to reinforce the importance of annual evaluations being completed for all patients enrolled on the clinic for more that one year, Evaluations are to be completed on, or shortly before, the patients' anniversary date. The clinical coordinator and clinical supervisor be responsible and will monitor and assure compliance during individual staff supervision. Compliance will also be monitored during quality record reviews and monthly Performance Improvement committee meetings. |
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 the review facility documentation that included incident reports and staff discussions, the facility failed to provide documentation of incident reports to the Department.
The findings include:
During the October 15-17, 2012 methadone monitoring, the facility provided documentation of incident reports that identified unusual incidents.
Incidents that were to be reported include an incident dated January 29, 2012 when police entered the premises for a "false" report of a stun gun.
On March 8, 2012, a patient was found lying on the ground outside of the facility and was transported to the emergency room after 911 was called.
On April 25, 2012, a patient presented intoxicated and sedated. 911 was called and the patient was transported to the emergency room as a possible overdose.
On May 21, 2012, a patient presented with a possible drug overdose, 911 was called and the patient was transported to an emergency room.
On July 1, 2012, a patient overdosed. 911 was called and the patient was administered Narcan and transported to the emergency room.
On July 30, 2012, a patient presented with what was eventually identified as scabies.
None of these reports were sent to the Department as required.
A discussion with facility staff confirmed that the facility was aware of the requirement to notify the Department of unusual incidents within 48 hours.
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Plan of Correction
All staff will be educated regarding all of those incidences that most be reported to the state within 48 hours of their occurrence. The nursing supervisor will report both the incident and the follow-up with the state during each monthly Performance Improvement committee meeting. Both the nursing supervisor and the clinical coordinator will be responsible to assuring that the required report has been sent to the state as required in 715.28(c)(1-5). |
704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on the review of administrative documentation, the facility failed to restrict the responsibilities full time clinical supervisor to those duties assigned to the position..
The findings include:
Administrative documentation that included the Narcotic Treatment Program Monitoring Questionnaire completed by the clinical director prior to the monitoring inspection, and the position description for the clinical supervisor were reviewed. The questionnaire requests caseload information for each clinical staff person. The caseload for the clinical supervisor was listed as 33 patients.
The position description was reviewed. The clinical supervisor is required be able to assume the responsibilities for the day to day clinical management in the absence of the clinical coordinator.
In addition to the patient caseload, it was reported to the licensing specialist during the survey that the clinical supervisor is also responsible for all admission intakes.
The full time clinical supervisor should carry a caseload of no more than five patients for the sole purpose of maintaining his/her clinical skills. This number should be reduced if the administrative duties are increased.
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Plan of Correction
Counselor caseloads will be re-configured to reduce the clinical supervisors caseload to no more than 3 patients. Patients will be re-distributed so that all counselors will have no more than 35 patients . each. The clinical coordinator will be responsible for implementation and monitoring to ensure compliance with the regulation 704.6(a) |