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 September 17 through 19, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, A.R.S. of Lancaster, LP was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on November 3, 2008.
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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 a review of 16 patient records on September 17 through 19, 2008, the narcotic treatment program failed to document that prior to the administration of an agent, the program screened each individual to determine eligibility for admission in three of four patient records were required.
Findings:
In patient record #4 documentation regarding the determination of the patient's physiological dependence for at least 1 year prior to admission for maintenance treatment indicated the patient had a history of drug-related criminal activity. There was no documentation in the record verifying the patient's history of drug-related criminal activity. In addition, documentation in the personal history indicated no prior drug-related criminal activity.
In patient record #5 there was no documentation of whether an individual is currently physiologically dependent upon a narcotic drug. The narcotic treatment physician did not document anywhere in the patient's record the determination of the individual's current physiological dependence upon a narcotic drug.
In patient record #16 the Certified Registered Nurse Practitioner conducted the 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 must make this determination and document in the patient's record the basis for this determination.
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Plan of Correction
The executive (facility) director will assign the ARS Medical Director to ensure that prior to administration of an agent, a ARS Lancaster shall screen each individual to determine eligibility for admission. ARS Lancaster shall: shall have it's Medical Director 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. ARS Medical Director shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
IN the event a patient with a history of drug-related criminal activity seeks admission the ARS Medical Director will ensure there is documentation in the record verifying the patient's history of drug-related criminal activity. In addition, documentation in the personal history will indicate prior drug-related criminal activity.
In addition the ARS Medical Director willensure that the Certified Registered Nurse Practitioner will not conduct the 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 ARS Medical Director will only make this determination and document in the patient's record the basis for this determination.
The above mentioned will be done by the following:
1. Prescreening of every patient for determination of requirements by Executive Director or Clinical Supervisor
2. Training of Medical Director and Nurse Practioner on requrements for admittance and proper documentation
3. Revise Forms to clearly define patient is physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment
4. Review of each newly admitted chart by ARS Medical Staff member to ensure proper documentation in place
5. Review existing charts with any defeciencies and update personal histories where indicated and document determination of the individual's current physiological dependence upon a narcotic drug.
It is the executive (facility) director's ultimate responsility to ensure this action plan is in compliance.
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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 a review of 16 patient records on September 17 through 19, 2008, 16 were required to contain documentation of random drug-screening urinalysis at least monthly. The narcotic treatment program failed to provide documentation of monthly drug-screening urinalysis results in three of sixteen patient records where required.
Findings:
In patient record #1 there was no documentation of a random monthly drug-screening urinalysis for the month of June 2008. This document was not presented during the on-site methadone monitoring.
There was no documentation that the narcotic treatment program conducted a complete drug-screening urinalysis for the prospective patient in patient record #4. Documentation in the record indicated the completion of the drug-screening urinalysis was dated September 5, 2008. The patient received an initial dose of methadone on September 4, 2008 prior to the completion of the urinalysis.
In patient record #8 there was no documentation of a random monthly drug-screening urinalysis for the month of July 2008. This document was not presented during the on-site methadone monitoring.
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Plan of Correction
The executive (facility) director will ensure that ARS Lancaster shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter. (1) Each test shall be for opiates, methadone, amphetamines, barbiturates, cocaine and benzodiazepines.
ARS Lancaster will ensure that the laboratory performing the initial drug-screening urinalysis (Health Network Laboratories) will included methadone in the test.
ARS has upgraded it's dispensing system (Methasoft) to ensure that every patient is flagged for a monthly urinalysis. The Nursing and Executive Director's will meet monthly to review compliance.
The ARS executive (facility) director has contacted Health Network Laboratories and has methadone added to the initial drug-screening urinalysis for each prospective patient.
It is the executive (facility) director ulitimate responsibility to ensure compliance in this area. |
715.14(a)(1) 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.
(1) Each test shall be for opiates, methadone, amphetamines, barbiturates, cocaine and benzodiazepines.
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Observations
Based on a review of 16 patient records on September 17 through 19, 2008, 16 patients were required to have completed initial drug-screening urinalysis for each prospective patient that included testing for opiates, methadone, amphetamines, barbiturates, cocaine and benzodiazepines. The narcotic treatment program failed to ensure that the laboratory performing the initial drug-screening urinalysis included methadone in the test in all 16 patient records reviewed, as required.
Findings:
In all 16 patient records, #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 ,13 ,14 ,15 and 16 the laboratory used by the narcotic treatment program to perform the initial drug-screening urinalysis for each prospective patient did not include a test for methadone. Documentation of the initial drug-screening urinalysis results in all 16 patient records revealed that the laboratory does not include the testing of methadone, which is required.
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Plan of Correction
The executive (facility) director will ensure that ARS Lancaster shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter. (1) Each test shall be for opiates, methadone, amphetamines, barbiturates, cocaine and benzodiazepines.
ARS Lancaster will ensure that the laboratory performing the initial drug-screening urinalysis (Health Network Laboratories) will included methadone in the test.
ARS has upgraded it's dispensing system (Methasoft) to ensure that every patient is flagged for a monthly urinalysis. The Nursing and Executive Director's will meet monthly to review compliance.
The ARS executive (facility) director has contacted Health Network Laboratories and has methadone added to the initial drug-screening urinalysis for each prospective patient.
It is the executive (facility) director ulitimate responsibility to ensure compliance in this area.
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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 a review of 16 patient records on September 17 through 19, 2008, the narcotic treatment program failed to document that the narcotic treatment physician determined the proper dosage level for each patient in five of five patient records where required.
Findings:
In patient records # 2, 3, 5, 9 and 15 the documentation on the dose order forms revealed that the Certified Registered Nurse Practitioner and Licensed Practical Nurses were initiating the dose order changes, rather than the Narcotic Treatment Physician. There was no documentation on those forms that the narcotic treatment physician was the individual determining and ordering the dose change, as required.
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Plan of Correction
The ARS executive (facility) director will ensure that the ARS Medical Director shall determine the proper dosage level for a patient. If the ARS physician determining the initial dose is not the ARS physician who conducted the patient examination, the ARS physician shall consult with the ARS physician who performed the examination before determining the patient 's initial dose and schedule.
This will be completed by the following:
A training of the ARS medical staff on proper procedures and documentation
Changing the existing form to show that the ARS physician was the individual determining and ordering the dose change, as required.
Review all orders by a ARS medical staff member on a regular basis.
It is the executive (facility) directors ulimate responsibility to ernsure compliance in this area. |
715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
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Observations
Based on a review of 16 patient records on September 17 through 19, 2008, the narcotic treatment program failed to document that the narcotic treatment physician determined the rationale for permitting take-home medication in three of sixteen records, as required.
Findings:
In patient records #3, 10 and 16 the documentation on the dose order forms revealed that the Certified Registered Nurse Practitioner was documenting the rationale for permitting take-home medication, rather than the Narcotic Treatment Physician. There was no documentation on those forms that the narcotic treatment physician was the individual determining the rationale for the take-home medication.
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Plan of Correction
ARS shall Ensure that the determination whether a patient may be provided take-home medications is made by the ARS Medical Director and will be documented in the patient record the rationale for permitting take-home medication.
The ARS Executive (facility) directer will meet with both of the ARS MD and NP to train them on this issue as well as ensuring docementation on forms indicates that the narcotic treatment physician was the individual determining the rationale for the take-home medication.
The ARS Executive (facility) director is ultimately responsible to ensure compliance in this area.
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715.16(c)(2)(i-iv) LICENSURE Take-home previliges
(c) A narcotic treatment program shall require a patient to come to the narcotic treatment program for observation daily or at least 6 days a week for comprehensive maintenance treatment, unless a patient is permitted to receive take-home medication as follows:
(2) A narcotic treatment program may permit a patient to reduce attendance at the narcotic treatment program for observation to two times weekly and receive no more than a 3-day take-home supply of medication when in the reasonable clinical judgment of the narcotic treatment physician, which is documented in the patient record:
(i) A patient demonstrates satisfactory adherence to narcotic treatment program rules for at least 2 years.
(ii) A patient demonstrates substantial progress in rehabilitation.
(iii) A patient demonstrates responsibility in handling narcotic drugs.
(iv) A patient demonstrates that rehabilitation progress would improve by decreasing the frequency of attendance for observation.
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Observations
Based on a review of 16 patient records on September 17 through 19, 2008, the narcotic treatment program failed to document the reasonable clinical judgement of the narcotic treatment physician for permitting a patient to reduce attendance at the narcotic treatment program for observation to two times weekly and receive no more than a 3-day take-home supply of medication. The documentation was not included in one of one patient record where required.
Findings:
In patient record #3 the documentation indicated that the patient was admitted to treatment on August 27, 2007. This patient would not be eligible for reduced attendance at the narcotic treatment program for observation to two times weekly until August 27, 2009. In addition, there was no documentation in the patient record of a request for an exception for the reduced attendance. This documentation was not presented during methadone monitoring.
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Plan of Correction
ARS shall require all patients to come to the narcotic treatment program for observation daily or at least 6 days a week for comprehensive maintenance treatment, unless a patient is permitted to receive take-home medication as follows: ARS may permit a patient to reduce attendance at the narcotic treatment program for observation to two times weekly and receive no more than a 3-day take-home supply of medication when in the reasonable clinical judgment of the narcotic treatment physician, which will be documented in the patient record: Patient demonstrates satisfactory adherence to narcotic treatment program rules for at least 2 years. Patient demonstrates substantial progress in rehabilitation. Patient demonstrates responsibility in handling narcotic drugs. Patient demonstrates that rehabilitation progress would improve by decreasing the frequency of attendance for observation.
ARS will ensure documention of the reasonable clinical judgement of the ARS physician for permitting a patient to reduce attendance at the narcotic treatment program for observation to two times weekly and receive no more than a 3-day take-home supply of medication.
ARS will also ensure that proper documentation will be in the patient record of a request for any exception for reduced attendance. The ARS Medical Director and Clinical Supervisor will review these on a case by case basis and ensure submission to state for exception and proper documentation is in the patient chart.
The ARS executive (facility) director and the ARS clinical supervisor will conduct a training with ALL ARS staff including ARS Medical director to ensure the above is reviewed. The ARS Clinical supervisor will review each patients eligibility for take homes prior to presenting to the ARS Medical Director for final review and approval, this will ensure criteria for take homes are met.
It is the ARS Executive (facility) Directors ultimate responsibility to ensure compliance in this area. |
715.16(f) LICENSURE Take-home priveleges
(f) An exception granted under subsection (d) shall continue only for as long as the temporary disability or exceptional circumstance exists. When a patient is permanently disabled, that case shall be reviewed at least annually to determine whether the need for the exception still exists.
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Observations
Based on a review of 16 patient records on September 17 through 19, 2008, the narcotic treatment program failed to document that the narcotic treatment physician reviewed at least annually, where a patient is permanently disabled, whether the need for the exception still exists. One of sixteen patient records was required to contain this documentation.
Findings:
In patient record #1 there was no documentation indicating that the narcotic treatment physician reviewed the patient's need for the ongoing exception. This documentation was not presented during methadone monitoring. Patient #1 was admitted to the narcotic treatment program on December 6, 2006. The original documentation by the physician regarding the patient's permanent disability was dated October 18, 2006. The annual review was due on or by October 18, 2007. This document was not presented.
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Plan of Correction
ARS will ensure any exception granted under subsection (d) shall continue only for as long as the temporary disability or exceptional circumstance exists. When a patient is permanently disabled, that case shall be reviewed at least annually to determine whether the need for the exception still exists. The ARS executive director will meet with the Medical Director and Clinical Supervisor to review. The ARS Executive Director will also review for compliance each month during the monthly medical team meeting with the Medical Director. ARS Executive Director will also ensure this is entered into the Methasoft computer system to automatically flag any patient for the annual review. ARS Medical Director will check methasoft system each month to ensure compliance is met and all flagged patients annual reviews are completed. All current patients will be reviewed for continuation of exception and results will be documented into patient chart. It is the ARS executive directors responsibility to check the methasoft system each month and ensure compliance in this area.
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715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of 16 patient records on September 17 through 19, 2008, the narcotic treatment program failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first 2 years. This is required in all sixteen records reviewed.
Findings:
In three of sixteen records reviewed, #6, 10 and 11, the narcotic treatment program failed to document that each patient was provided with an average of 2.5 hours of psychotherapy per month.
In patient record #6, the patient received no psychotherapy services from May 15, 2008 through July 15, 2008. There was no documentation in the record or presented during methadone monitoring indicating why the patient did not receive the required average hours of psychotherapy.
In patient record #10, the patient received an overage of one hour of psychotherapy from the date of admission on May 6, 2008 through August 31, 2008. There was no documentation in the record or presented during methadone monitoring indicating why the patient did not receive the required average hours of psychotherapy.
In patient record #11, the patient received an average of 2.25 hours of psychotherapy services from February 16, 2008 through June 16, 2008. There was no documentation in the record or presented during the methadone monitoring indicating why the patient did not receive the required average hours of psychotherapy.
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Plan of Correction
ARS shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in treatment.
The ars executive director has assigned the ars clinical supervisor the duty to remain compliance in this area. This will be done by the following: ARS has upgraded it's Metasoft system to include ability to track and review counseling conpliance. The clinical supervisor and executive director will review each ccounselors assigned compliance logs monthly. A peer review and auditing process is now in place to seek any patients not meeting currenty compliance and proper documentation will be placed in any patients charts of reason indicating why the patient did not receive the requie=red counseling.
A staff training will be held to teach clinical staff that minimumstandars are just minimum but more counseling as per patients needs is best practice.
It is the ars executive directors ulimate responsibility to ensure compliance in this area. |
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 a review of 16 patient records on September 17 through 19, 2008, the narcotic treatment program failed to transfer patient files, with the written consent of the patient, to the receiving narcotic treatment program in two of the three patient records where required.
Findings:
In patient records #6 and 13, the narcotic treatment program failed to document in the patient record that information in the patient's file was sent to the receiving narcotic treatment program. In addition, there was no documentation in the patient record indicating the patient signed a consent to release information form. These documents were not presented during methadone monitoring.
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Plan of Correction
ARS will ensure to transfer patient files, with the written consent of the patient, to the receiving narcotic treatment.
ARS will ensure to document in the patient record that information in the patient's file was sent to the receiving narcotic treatment program. In addition, ARS will ensure proper documentation in the patient record indicating the patient signs a consent to release information form.
This will be done by the clinical supervisor reviewing each patient chart to prior to transfer to ensure proper documentaion and release of information/consents are in place as well as after the transfer to ensure documentation of transfer is completed and in the transferring patients chart.
A training by the clinical supervisor for the ck=linical staff will also take place to review this defiency. It is the ARS executive directors responsibility to remain compliant in this area. |
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
In 16 patient records reviewed on September 17 through 19, 2008, the narcotic treatment program failed to document an annual re-evaluation of the patient by the narcotic treatment physician in three of three patient records where required.
Findings:
In patient records #3 and 15, the Certified Registered Nurse Practitioner completed the annual re-evaluation. This annual re-evaluation must be completed by the narcotic treatment physician.
In patient record #8, the annual re-evaluation was to be completed on or before May 11, 2008. The annual re-evaluation, dated June 13, 2008, was late.
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Plan of Correction
ARS will ensure to document all annual re-evaluation of patients by the ARS physician
ARS will not allow Registered Nurse Practitioner to completed the annual re-evaluation. This annual re-evaluation will only be completed by the ARS physician.
ARS will ensure that annual re-evaluation will be complete within the requred time lines. This will be done by using the upgraded methasoft computer system to track all annual re evaluations and schedule them prior to annual date. The executive director will meet with th MD and NP to clarify this and will review the annual re evaluation wiy=th the director of nursing on a monthly basis to ensure compliance. The ARS executive director is ulimately responsible forr compliance in this area.
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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 a review of 16 patient records on September 17 through 19, 2008, the narcotic treatment program failed to document in the patient records the results of laboratory tests or other special examinations given by the narcotic treatment program in two of four patient records where required.
Findings:
In patient record #16, the Mantoux test was not document in the patient's record. The test was not present during the methadone monitoring.
In patient record #4, the Serological test was not documented in the patient's record. The test was not present during the methadone monitoring.
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Plan of Correction
ARS will ensure documention in all the patient records of the results of laboratory tests or other special examinations given by ARS.
All Mantoux test was will be documented in the patient's record upon completion.
All Serological test will be documented in the patient's record.
ARS will ensure compliance by ensuring that all patients will be entered into the upgraded methasoft system and tracked and will be flagged when they are due. The ARS executive director and Nursing Director will review this monthly. A training on compliance in this area will be conducted with the ARS medical Staff. It is the ARS vexecutive directors responsibilirty to ensure compliance in this area.
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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 a review of 16 patient records on September 17 through 19, 2008, the narcotic treatment program failed to document a psychosocial evaluation in three of five patient records where required.
Findings:
In patient record #10, the psychosocial evaluation was not documented. The patient was admitted to the program on May 6, 2008. As required by the narcotic treatment program, the psychosocial evaluation is to be completed within 30 days of the patient's admission.
In patient records #3 and 6, the psychosocial evaluation was a repeat of the patient's historical information and contained patient generated comments rather than the clinician's impression of the patient's needs based on the historical information gathered.
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Plan of Correction
As of 10-27-08, Clinical supervisor will review all new patients charts for the next 90 days to ensure psychosocial evaluations are in compliance.
On 10-27-08, The ARS Clinical Supervisor will also conduct an hour training for all clinican's on psychosocial evaluations. The training will concentrate on completing psychosocials within 30 days of the patient's admission, not to repeat the patient's historical information, and not to contain patient generated comments and to include clinician's impression of the patient's needs based on the historical information gathered.
It is the ARS Clinical Supervisor's responsibility to ensure compliance is met.
In addition, Clinical Supervisor will conduct on going chart reviews for each counselor at least on a monthly basis. |