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 13-16, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Consortium 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 and a plan of correction is due on August 23, 2010.
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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.
The findings include:
Physician time sheets and and census reports for the months of March, April, May, June and July were reviewed on July 13, 2010. There were insufficient onsite physician hours at various times during March, April and May 2010.
During the month of March 2010, the census ranged between 345 and 352 patients. Therefore, the minimum onsite physician hours required for the month of March 2010 was 34.5 hours per week. During the week of March 20-26, 2010 there were 33 physician hours logged.
During the month of April 2010, the census ranged between 363 and 367 patients. Therefore, the minimum onsite physician hours required for the month of April 2010 was 36.3 hours per week. During the weeks of April 3-9, 2010 and April 10-16, 2010 there were 29 physician hours logged each week. During the week of April 17-23, 2010 there were 33 physician hours logged.
During the month of May 2010, the census ranged between 369 and 374 patients. Therefore, the minimum onsite physician hours required for the month of May 2010 was 37 to 37.5 hours per week. During the week of May 1-7, 2010 there were 21 physician hours logged. During the week of May 8-14, 2010 there were 30 physician hours logged. During the week of May 15-21, 2010 there were 23 physician hours logged. During the week of May 22-28, 2010 there were 33 physician hours logged.
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Plan of Correction
Plan of Correction:
M025
715.6(d) Physician Staffing:
Responsible Party(s):
The Nursing Supervisor will be responsible for submitting weekly schedules for the narcotic treatment physicians 2 weeks in advance to ensure that the program provides at least 1 hour per week of onsite physician time for every ten patients.
Timeframe for Completion:
Verification of Physician Staffing schedules will be submitted to the Facility Director two weeks in advance beginning September 1, 2010
Monitoring:
The Medical Director, Facility Director and Nursing Supervisor will work collaboratively to monitor physician staff time to ensure that the program is providing at least 1 hour per week of onsite physician time for every ten patients at all times.
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715.10(d) LICENSURE Pregnant patients
(d) Within 3 months after termination of pregnancy, the narcotic treatment physician shall enter an evaluation of the patient 's treatment status into her record and state whether she should remain in comprehensive maintenance treatment or receive detoxification treatment.
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Observations
Based on the review of patient records, the narcotic treatment program failed to document, within three months after the termination of pregnancy, whether or not the patient should continue maintenance or receive detoxification treatment in one of one pregnant patient records.
The findings include:
Twenty-two patient records were reviewed July 13-16, 2010. Two records were those of patients with a recent pregnancy termination. An evaluation of the patient's treatment status within three months after termination of pregnancy was required in one patient record. The narcotic treatment program, specifically the physician, did not document this evaluation that was due by May 20, 2010 based on the patient's termination of pregnancy on February 20, 2010. The physician met with the patient on March 18, 2010 but never documented a post partum evaluation in patient record #12.
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Plan of Correction
Plan of Correction:
M083
715.10(d) Pregnant patients:
Responsible Party(s):
The Medical Director and the Nursing Supervisor will be responsible for ensuring that within 3 months after termination of patient pregnancy, the narcotic treatment physician documents an evaluation of the patient's treatment status, as well as whether or not the patient will remain in comprehensive maintenance treatment or receive detoxification treatment.
The Nursing Supervisor will be responsible for ensuring that all pregnant patients are scheduled for a post-partum evaluation within 3 months of termination of pregnancy.
Timeframe for Completion:
The Medical Director will be responsible for ensuring that all narcotic treatment physicians are trained to document a 3 month post-partum evaluation by September 15, 2010.
Monitoring:
The Medical Director will provide ongoing supervision to the narcotic treatment physicians to ensure that post partum evaluations are completed within 3 months of termination of pregnancy.
The Nursing Supervisor will review records of post partum patients to ensure that the required 3 month evaluation is completed as scheduled.
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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 a review of patient records, the facility failed to ensure the consents to release information were in accordance with 42 CFR 2.22 and 4 Pa Code 255.5 in six of seven patient records reviewed.
The findings include:
Twenty two patient records were reviewed July 13-16, 2010. Six patient records were reviewed specifically for compliance with confidentiality requirements.
Patient record # 2 contained the full name of another patient enrolled in the facility as part of an incident report.
Patient record # 7 contained a signed consent to release information to the patient's primary care physician without identifying the physician or the physician's practice.
Patient record # 9 contained four signed (by patient)blank consent forms..
Patient record # 11 contained a consent to release urine drug screen results to the patient's child welfare case worker.
Patient record # 16 contained a signed blank consent for the patient's funding source.
Patient record # 10 contained an agreement signed by the pregnant patient that the facility would contact the Child Protective Services and "other authorities" if she tested positive for illicit drugs.
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Plan of Correction
Plan of Correction:
M093
715.11 Confidentiality of patient records
Responsible Party(s):
Clinical Staff, including Clinical Supervisors, Intake staff, and Clinical Counseling staff, are responsible for ensuring that patient files maintain confidentiality and contain valid consents to release patient information.
Time Frame for Completion:
The Facility Director and Clinical Supervisors will be responsible for ensuring that all Clinical staff, including intake staff, is trained on the proper and full completion of consents to release information. This training will also focus on what information can and cannot be released with the patient's consent
This training will take place by September 15, 2010.
Monitoring:
The Facility Director, Clinical Supervisors, and Clinical Counseling staff will review client files during monthly supervision to ensure compliance with this standard.
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715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on the review of patient records, the facility failed to transfer all of the required information in two of four patient records.
The findings include:
Twenty-two patient records were reviewed July 13-16, 2010. Four patient records were reviewed for documentation of the patient files that were sent to the receiving narcotic treatment facility.
Patient # 3 had no documentation of any records being sent and the consent signed by the patient only listed attendance and prognosis as the information to be released to the receiving facility.
Patient # 4 contained a statement in the discharge summary that the patient was referred to another narcotic treatment facility, but there was no other documentation of records being sent to the receiving facility.
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Plan of Correction
Plan of Correction:
M193
715.20(1): Patient transfers
Responsible Party(s):
Clinical Counseling Staff has the responsibility of ensuring that the records of patients being transferred to another narcotic treatment program for continued maintenance, detoxification or other treatment activity; have the required documentation transmitted to the receiving facility.
This information includes an admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, current status of the patient, as well as the written consent of the patient to be transferred.
Timeframe:
The Facility Director and the Clinical Supervisors will be responsible for training Clinical Counseling Staff on the submission of the required documentation to the receiving facility of transferred patients by September 15, 2010.
Monitoring:
The Clinical Supervisors will be responsible for reviewing all patient transfer documentation prior to the information being transmitted to another narcotic treatment facility in order to ensure that all required elements are present.
Monthly patient record reviews and ongoing clinical supervision will also be conducted by the Clinical Supervisors and the Facility Director to ensure compliance with this standard on an ongoing basis.
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715.23(b)(11) LICENSURE Patient records
(b) Each patient file shall include the following information:
(11) Counselor notes regarding patient progress and status.
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Observations
Based on the review of patient records, the facility failed to maintain current progress notes in four of ten patient records.
The findings include:
Twenty two patient records were reviewed July 14-16, 2010. Ten patient records were specifically reviewed for documentation of patient's progress. Three patient records did not have current information:
Patient # 15 had no progress notes since April 27, 2010. There was no indication of the patient continuing to attend or whether the patient was no longer attending as the record of service and treatment plan update was also dated in April 2010.
Patient # 16 had no progress note documentation since February 18, 2010 and the record of service identified the last clinical contact as April 19, 2010.
Patient # 19 had no progress information documented since February 4, 2010 and the record of service had the last service contact as March 15, 2010 and a treatment plan update dated May 13, 2010.
Patient # 7 contained individual session notes that failed to provide information to demonstrate patient's progress or status. The notes were written in D(ata) A(assessment) and P(lan) format. The D had no information of the patient; A was more data and P did not reflect the D & A sections of the note.
Patient record # 10 had group notes without an assessment or a plan.
patient record # 22 contained multiple progress notes with the same assessment and plan.
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Plan of Correction
Plan of Correction:
M237
715.23(b) (11): Patient records
Responsible Party(s):
The Clinical Counseling Staff and the Clinical Supervisors are responsible for ensuring that the patient record includes Counselor notes regarding patient progress and status.
Medical Records staff is responsible for ensuring that Counselor notes are filed into the patient record once received from the Clinical Staff, and kept current.
Timeframe for completion:
The Clinical Counseling staff and Clinical Supervisors will receive training regarding the importance of completing notes within 24 hours of the provision of the service delivered, as well as the proper completion of DAP group and individual notes by September 15, 2010
The Medical Records staff will be trained regarding the importance of filing Counselor Notes into the patient record in a timely manner by September 15, 2010.
Monitoring:
The Clinical Supervisors will be responsible for providing bi-weekly to monthly supervision to Clinical Staff ensuring that Counseling notes are kept current.
The Facility Director will provide weekly to bi-weekly supervision to the Medical Records staff to ensure timely filing of Counselor Notes into the patient record.
The Facility Director and Clinical Supervisors will review patient records on a bi-weekly to monthly basis in order to ensure continued compliance with this standard.
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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 the review of patient records, the narcotic treatment program failed to document discharge summaries within the required time-frame in two of five patient records.
The findings include:
Twenty two patient records were reviewed July 13-16, 2010. Discharge summaries were reviewed in five patient records.
In patient records # 6 and 8 the discharge summaries were not completed within seven days from the date of the patients' discharge.
Patient # 6 was discharged as deceased. The patient's relative called the facility May 25, 2010 to report the patient suffered a massive heart attack and died on May 17, 2010. The facility had seven days to complete the discharge summary. However, the discharge summary was not documented until June 6, 2010.
Patient # 8 was discharged as deceased. The patient reportedly died in a hospital emergency room on April 5, 2010. According to the therapist's documentation, the therapist was notified of the death on April 7, 2010 An incident report was completed and faxed to the funding source on April 9, 2010. The discharge summary was due to be completed by April 14, 2010, but was not completed until May 11, 2010.
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Plan of Correction
Plan of Correction:
M261
715.23(b)(23): Patient records
Responsible Party(s):
The Clinical Counseling Staff and the Clinical Supervisors are responsible for ensuring that a complete discharge summary is documented within seven days of patient discharge.
Timeframe for completion:
The Facility Director and Clinical Supervisor will train the Clinical Counseling staff regarding the completion of a comprehensive discharge summary within seven days of discharge by September 15, 2010.
Monitoring:
The Clinical Supervisors will be responsible for providing bi-weekly to monthly supervision to Clinical Staff ensuring that discharge summaries are completed as required.
The Clinical Supervisors and the Facility Director will review patient records to monthly to ensure continued compliance with this standard
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