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 November 1-3, 2011 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, Inc., 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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715.11 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 the review of patient records, the facility failed to restrict the information released to that which the patient consented in six of eleven patient records reviewed.
The findings include:
Fourteen patient records were reviewed November 1-3, 2011. Eleven patient records were reviewed specifically for documentation of consent to release information documentation.
Patient records # 7, 8, 9, 10, 17 and 18 contained signed consents to release information for the patient's funding source that was restricted to only the enrollment and attendance information.
Patient record # 7 contained a consent to release that was signed by the patient that did not include what information was going to be released.
Patient record # 10 contained documentation of information released to a government funding agency that exceeded 4 PA Code 255.5. The consent to release signed by the patient allowed all assessments, medication records and urine drug screens to be released.
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Plan of Correction
AMHA will conduct a staff training to address the three aspects outlined as being deficient. Specifically, the training will instruct staff on the specific and complete information that is to be released, the purpose of the release, the limitations imposed on the release and full compliance with 40 PA 255.5(b). The Clinical Coordinator will be responsible for providing the training and will monitor conformance. Conformance will also be monitored via chart audits during the Quality Record Reviews which is conducted by a member of the Performance Improvement Committee. |
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 seven of twelve patient records.
The findings include:
Fourteen patient records were reviewed November 1-3, 2011. Twelve patient records required at least one case consultation at the time of the inspection.
Patient # 1 was admitted January 17, 2008. The patient was discharged March 1, 2011. The last documented case consultation was completed January 22, 2010. An annual evaluation, due January 2011 was required in the patient record.
Patient # 4 was admitted August 19, 2010. While there were quarterly case consultations documented, the only staff included as participating was the counselor who completed the document.
Patient # 7 was admitted October 3, 2008. The last documented case consultation was completed September 28, 2010. An annual evaluation, due in October 2011 was required in the patient record.
Patient # 9 was admitted February 11, 2011 and required quarterly case consultations up until discharge August 22, 2011. The only documented case consultation was not completed until July 19, 2011.
Patient # 12 was admitted September 21, 2010 and required quarterly case consultations through the patient discharge July 29, 2011. The first documented case consultation was not completed until February 24, 2011, but should have been documented by December 21, 2010.
Patient # 14 was admitted May 14, 2009. The patient required at least annual case consultations. While the annual case consultation was completed May 10, 2011, the only staff included as participating was the counselor who completed the document.
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Plan of Correction
AMHA will conduct a staff training to address the six areas defined as being deficient. Specifically, the training will address the regulations requiring that case consults be done quarterly for the first year and annually thereafter. It will also address the importance of timeliness of completion. Additionally, counselors will be trained regarding case consults requiring ideally members from each discipline,but at a minimum, two clinical staff participating. Also addressed will be the reqirement for completion of an annual justification for each patient on or immediately before their anniversary date. The Clinical Coordinator will conduct the training and be responsible for monitoring conformance. Conformance will also be monitored during internal chart audits conducted during Quality Record Reviews conducted by a member of the Performance Improvement Committee. |
715.23(d) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to prepare treatment plans outlining realistic treatment goals in six of eleven patient records reviewed.
The findings include:
Fourteen patient records were reviewed November 1-3, 2011. Eleven patient records were reviewed specifically for documented treatment plans. Four patient records failed to document realistic treat goals.
Patient # 5 was re-admitted March 15, 2011 and a new treatment plan was not completed nor was the last treatment plan prior to the March 3, 2011 medical discharge updated.
Patient record # 6 contained goal statements that could not be measured as written.
Patient record # 8 contained a short term goal of providing a urine drug screen, which is already a requirement of the facility and there was no documentation the patient was non-compliant in this area.
Patient record # 13 contained patient's documented desires and were not written goals.
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Plan of Correction
AMHA will conduct a staff training to address the four areas outlined as being deficient. Specifically, the training will focus on the development and content of treatment plans for persons in recovery. Counselors will be trained on the importance of treatment plans being recovery oriented, behaviorally defined and measurable. The training will focus on what measurable goals involve and how to devise them. Counselors will also be trained on the re-admission process and the required paperwork and timeframes for completion. The Clinical Coordinator will be responsible for conducting the staff training and monitoring conformance. Conformance will also be monitored during internal chart audits as part of the Quality Rocord Review that will be conducted by a member of the Performance Improvement Committee. |
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 of patient records, administrative documentation and discussion with administrative staff, the facility failed to report unusual incidents to the Department within 48 hours as required.
The findings include:
Fourteen patient records were reviewed November 1, 2011. Administrative documentation that included unusual incident reports was reviewed November 2, 2011. A discussion with the medical director, the project director and the clinical director regarding the documented unusual incident reports was conducted November 3, 2011.
The following incidents were documented but not reported to the Department:
On 2/21/11 police were called onsite due to patient threats to others.
On 5/29/11 police chased a patient into the building & confiscated illicit pills.
On 7/13/11 a patient presented with symptoms of overdose and 911 was called.
On 7/26/11 a patient appeared to overdose on the premises, 911 was called and EMT 's arrived and administered Naloxone, a drug used to counter the effects of opiate overdose.
Two patient deaths were not reported as required. The facility failed to provide the Department with written reports that provided an account of the patient deaths.
In addition, the nursing staff had reported during this inspection that a vial of Mantoux PPD was missing from the physician's office after the physician had met with patients. There was no documentation of an incident report.
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Plan of Correction
Unusual incidents will be reported as required in 715.28(c)(1-5) The Project Director will ensure that that all incidents as listed in the regulation will be reviewed and submitted to the Department within the 48 hout requirement. This includes reporting of deaths, major medical emergencies, acts of violence and threats within the facility. All incidents involving loss of medications will be documented in an incident report log and maintained in our health and safety manual. Any reportable loss of medications will also be reported to the appropriate agencies. The medical staff will be reminded of the importance of safeguarding all medications and medical equipment while seeing patients. The project director and medical director will be responsibile for conformance. |