INITIAL COMMENTS
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This report is a result of a complaint investigation conducted by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings, 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. The following deficiencies were identified and a plan of correction is due June 23, 2009. .
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Plan of Correction
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715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on patient record review and an interview with the Executive Director, the facility failed to document a physician's order to change patient dosing schedules in one of twelve records reviewed.
The findings include:
Twelve patient records were reviewed on June 3, 2009. Dosing orders were required in all twelve records.
Documentation in the patient record identified that patient # 7 had been the recipient of an involuntary discharge letter on May 21, 2009. Additional documentation in the patient record identified a ten day involuntary detoxification was scheduled to begin May 27, 2009; the patient record did not contain documentation of a physician's order that initiated the involuntary detoxification. An interview with the Executive Director on June 6, 2009 addressed the failure to have a physician order that pertained to the involuntary detoxification of the patient. The Executive Director expressed surprise that there was no order contained in the patient record and reported there had been discussions with the physician regarding patient # 7. He agreed there was no physician order in patient record # 7 that ordered the involuntary detoxification of patient # 7.
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Plan of Correction
ARS Executive Director located physician's order to change patient dosing schedule for patient # 7 in the methasoft system. It wasn't in patient #7 chart because primary therapist had the order in his office and hadn't filed it in patients chart.
ARS Medical Director along with ARS Executive Director will monitor to ensure all physicians orders are signed and completed immediately and placed in patients charts and not just entered into the methasoft system.
Executive Director will also review at next staff meeting to ensure all physicians ordered are placed in patient charts immediately. |
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 patient records, the facility failed to document that patients received an average of 2.5 hours during the first two years of treatment in one of five records reviewed.
The findings include:
Twelve patient records were reviewed on June 3, 2009. Documentation of psychotherapy hours were reviewed in five patient records. The facility failed to document psychotherapy hours in patient record # 7 from February 25, 2009 through March 28, 2009. During the June 3, 2009 interview with the Executive Director the lack of documentation in patient record # 7 was reviewed and acknowledged. The Executive Director related he knew the patient's counselor was working with the patient during this time frame but without documentation of the contacts there was no validation that the contacts had occurred.
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Plan of Correction
The ARS facility director delegates the resposibility to monitor patients receiving an average of 2.5 hours counseling during the first two years of treatment, to the ARS Clinical Supervisor
The ARS clinicial supervisor will track all patients counseling compliance in the methasoft system. ARS clinical supervisor will review with counseling staff weekly to ensure patients recieve thier 2.5 hours of counseling. The ARS Clinical supervisor will be responsible for training the clinical staff to review their caseload weekly to ensure counseling compliance.
The ARS Clinical Supervisor will review each chart of patients that may be in danger of non compliance to ensure assigned counselors documentation is appropriate. This will happen on a weekly basis.
Patients who are non compliant within the first week of the month will see their primary counselor the following week to ensure monthly compliance. The patients primary counselor and the clinical supervisor, if necessary, will develop a plan for the patient to maintain clinical hours require by state regulations.
The ARS Clinical Supervisor will provide a training for clinical staff on proper monitoring and intervention techniques to engage patient into counseling compliance
The ARS executive director is responsible for the above action plan and will monitor bi-monthly for compliance.
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715.21 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.
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Observations
Based on a review of patient records and staff interview, the facility failed to provide documentation that all efforts had been made to retain the patient in treatment in one of four records.
The findings include:
Twelve patient records were reviewed on June 3, 2009; four of the records were reviewed for involuntary discharge content. The facility failed to document all efforts that had been performed to retain patient # 7 in treatment. The facility documentation specified that patient # 7 had failed to comply with treatment plans but did not specify what treatment and services had been afforded this patient. An interview with the Executive Director on June 3, 2009 addressed this issue and the Executive Director agreed the facility had failed to document all the treatment efforts that had been made to assist the patient.
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Plan of Correction
Addiction Recovery Systems disputes this citation that we failed to provide documentation that all efforts had been made to retain patient #7 in treatment for the following reasons:
Patient #7 signed a treatment plan for financial non compliance on 1-20-09. He signed and agreed to a payment plan each week, was instructed to go to the Department of Public Welfare and apply for medical assistance benefits, and agreed he was responsible for all unpaid fees associated with his treatment.
On 1-21-09 Patient #7 was placed on a behavioral contract for inappropriate and vulgar language/verbal assault directed toward staff or another patient, making threats of physical violence toward staff and patients, and required attendance for all appointments.
On 3-24-09 Patient #7 met with the ARS Office Manager regarding his overdue balance and non compliance with his treatment plan and was instructed to go to the medical assistance and apply for benefits. He refused.
On 3-24-09 Patient #7 treatment plan stated he needed to resolve his financial issues. Patient refused to sign his treatment plan.
On 4-28-09 Patient #7's primary counselor addressed his non compliance of not following his treatment plan due to financial non compliance.
On 5-18-09 ARS Executive Director met with Patient #7 regarding his non compliance of his treatment plan. Patient #7 stated he was unable to comply with his treatment plan and we would have to involuntarily discharge him.
On 5-20-09 ARS Executive Director and patient #7's primary counselor met with him to review the involuntary discharge procedures. Patient #7 was verbally abuse toward Executive Director and stated, "Do you want to go out in the parking lot and we can take care of this issue between us." Due to his inappropriate behavior the meeting was stopped and rescheduled for 5-21-09.
On 5-21-09 Executive Director and patient #7's primary counselor reviewed the involuntary discharge paperwork with the patient. Patient # 7 requested a fair hearing and one was scheduled for 5-26-09 @ 10:00.
On 5-26-09 Patient #7 failed to appear for his Fair hearing and was found to be non compliant with his treatment plan and a 10 day administrative detoxification would start on 5-27-09.
To ensure that proper documentation of clinical efforts to assist the patient are present, the ARS Clinical Supervisor is delegated to review any and all charts of patients that are in non compliance or may be in danger of becoming non compliant to ensure the assigned counselor properly documents in writing each and every intervention.
The ARS Clinical Supervisor will also hold an in service training for all clinical staff on proper documentation skills as well as documentation of refferals.
It is the ARS Executive Directors ultimate responsibility to ensure compliance in the areas noted above. |
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 a review of twelve patient records and a staff interview the facility failed to limit reasons for involuntary discharges to those reasons identified in the regulations in two of six records.
The findings include:
Twelve patient records were reviewed on June 3, 2009. Six records were reviewed for discharge content or documentation that addressed the potential for discharge.
Documentation in patient record # 7 identified the patient received a letter of involuntary termination on May 21, 2009 that specified the reason for discharge as being "noncompliance following treatment plan options/financial noncompliance". The facility failed to comply with the regulations when they stipulated the patient would be discharged for financial noncompliance.
Documentation in patient record # 4 addressed this patient's financial noncompliance. Patient # 4 entered treatment at this facility on November 12, 2008. At the time of admission the patient identified she was "broke". On December 23, 2008, the patient signed a payment plan to pay $342 in financial arrears; per this agreement, she was scheduled to make three weekly payments of $110 and one payment of $12. This payment plan stipulated that "failure to meet the terms set forth in this contract will result in discharge".
The issue of patient termination for financial noncompliance was addressed with the Executive Director on June 3, 2009. He acknowledged awareness that financial noncompliance was not a reason for involuntary discharge. In reviewing the case of patient #4 he related the wording of the software program, and not the facility practice, was reflected in the payment plan documentation. Regarding patient # 7, he acknowledged the documentation failed to specifically address patient issues in treatment.
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Plan of Correction
The ARS Executive Director delegates the clinical supervisor to review any patient that may be in danger of early termination due to non compliance to ensure every effort has been attempted to retain patients into treatment as well as every effort is made to refer patients to proper referral sources. The documentation of these interventions will be noted in the patient chart in the progress note session and will be written in DAP formula signed and dated. The ARS Clinical Supervisor will also review all counselor caseloads to ensure patients are seen according state mandated regulations are meet or exceeded.
Any patient that has been found to be in non compliance with the treatment goal "to remain financialy compliant with treatment fees" will have as many clinical interventions as deemed necessary by the ARS Executive and Medical Director, these interventions will review possible alternatives such as Medicaid, CBNP, CCBH, County funding, church assistance to help assist patients to get compliant each and every clinical intervention will be documented. Each referral will be documented as well as any refusal for referrals will be documented.
ARS will afford every oppertunity to any patient til it is deemed by the ARS Executive and Medical Director that all other eforts have failed.
The ARS Clinical Supervisor will assist the primary counselor in engaging the patient to seek assistance and ensure the primary counselor properly documents interventions.
The Clinical Supervisor will provide an inservice training on clinical interventions and referring patients as well as proper documentation skills.
It is the ARS Executive Directors overall responsibility to ensure compliance with the above plan.
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