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 August 28, 29, and 30, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Kirkbride Center 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 during this inspection and a plan of correction is due on September 20, 2007. .
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Plan of Correction
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715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on the review of eight patient records, the facility failed to verify the individual's identity, address, date of birth and other identifying information in six of the eight patient records, #2, 3, 4, 5, 6 and 8, prior to the administration of an agent.
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Plan of Correction
1. Verification of date of birth will continue to occur through the statewide Eligibility Verification System. Confirmation of age is made through the combination of date of birth and Social Security number.
2. Identification is asked of all patients when they arrive at the facility to be considered for admission. Identification may include a photo identification card, bill with name and address attached, wristband and collateral data from other referring agency such as hospital or Crisis Response Center.
3. As a Performance IMprovement Project, the Director of Admissions will collect data on so-called walk-ins, patients petitioning for admission without prior evaluation by a hospital or Crisis Response Center. The data to be collected with the percentage of prospective patients who petition for admission without photo identification.
4. The Performance Improvement investigation will be conducted by the Director of Admissions for one month.
5. Results will be forwarded to the state Division of Drug and Alcohol Program Licensure for further review. |
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 the review of nine patient records, the facility failed to ensure documentation of current physiological opioid dependency in five of the nine patient records reviewed, #2, 4, 6, 7 and 8.
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Plan of Correction
1. The Narcotic Treatment Physicians will document evidene of current physiologica dependence andat least a one-year history of physiological dependence (when applicable for maintenance treatment)on the Physician Documentation of Opiate Addiction form.
2. If a positive urine drug screen from a certified laboratory is not yet available at the time of assessment, the NTP will not check off Positive UDS for Opiates on the Documentation of Opiate Addiction form. Instead, the NTP will cite other evidence available at the time of assessment.
3. In such cases, the Positive UDS for Opiates will be checked off at the time results are available from a certified labortatory. The NTP will initial and date the entry on the form upon receipt of results from a certified laboratory.
4. The NPT in extreme cases will seek an exception to the requirement of current physiologic dependence through the Pennsylvania Department of Health, Division of Drug and Alcohol Program Licensure. |
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 six patient records, the facility failed to ensure the execution of a consent to release of information and instead obtained a consent to obtain information; failed to document the purpose of the consent and include the specific information to be released; specific information, where stated, exceeded 4 Pa Code 255.5; and had a blank consent to release information signed by the patient, specifically in records # 1, 2, 3, 4, 6 and 7.
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Plan of Correction
1. The first Back to Basics training for Admissions personnel will be conducted September 24, 2007, by the Director of Admissions. Training of all Admissions personnel will be completed well before the target date of October 31, 2007.
2. The Back to Basics training will re-educate all staff on the importance of consents, privacy rights and the correct completion of all consent forms.
3. The Senior Admissions Representative will conduct chart checks weekly to ensure compliance.
4. Results of the chart checks will be reported monthly for four months to the Executive Committee for oversight and monitoring beginning in November 2007. |
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 record reviews and staff interviews, the facility failed to ensure that the physician conducting the physical exam and the physician determining the initial dose consulted with each other prior to administering the first dose of methadone.
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Plan of Correction
1. The program has developed a Review of Systems form that the Narcotic Treatment Physician, at the time of assessment, has been completing prior to the initial administration of methadone. The NTP conducting the initial assessment also will write the order for the initial dose of methadone.
2. The Review of Systems form has been presented to the Pennsylvania Department of Health, Division of Drug and Alcohol Program Licensure, for review.
3. Completion of the Review of Systems form will be supplemented within 24 hours by the completion of a History and Physical Evaluation by the facility's Physician's Assistant. |
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 patient records, the facility failed to ensure the psychosocial evaluation contained evaluative commentary of the historical data obtained from the patient, and did not provide a composite assessment of the patient based on the information obtained in six of six patient records reviewed, #1, 2, 3, 4, 5 and 6.
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Plan of Correction
1. The Clinical Supervisors together with the Facility Director in regular supervision sessions have been re-training Primary Therapists is how to effectively write a case conceptualization narrative based upon data obtained in the biopsychosocial interview, as well as data derived from collateral sources and various psychometric measures such as the Basis 24.
2. Routine open-chart audits by the Clinical Supervisors and the Facility Director will determine the effectiveness of the case conceptualizaton narrative in providing a composite assessment of each patient.
3. Results of their open-chart audits will be reported monthly for four months to the Executive Committee for oversight and monitoring.
4. One Clinical Supervisor and two Primary Therapists will participate in a training with Aaron T. Beck, MD, at the Institute for Cognitive Therapy in December 2007. That training will focus on creation of a case conceptualization that is a composite assessment. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on record review of six patient records and the review of policy and procedures, the facility failed to ensure follow up contact was completed and documented according to the program policy in three of the six patient records reviewed, #5, 7 and 8.
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Plan of Correction
1. Within seven days of each patient's discharge, the two Clinical Supervisors will review each patients closed medical record to ensure completion of the seven-day follow-up form.
2. The supervisors will follow up with the Primary Therapist to ensure that the seven-day follow-up is completed.
3. Results will be reported monthtly to the Executive Committee for four months for oversight and monitoring. |
715.23(d)(2) 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.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Based on a random review of patient records, the facility failed to document the progress or lack of progress in achieving the goal statements from the prior treatment plan and the status of the goals in one of one patient record reviewed, # 4.
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Plan of Correction
1. The Facility Director and the Clinical Supervisors will conduct a training for all Primary Therapists. The training is designed to improve treatment plan documentation on a number of fronts.
2. The training will focus on the appropriate documentation of progress or lack of progress made in attaining previous treatment goals. That assessment will be incorporated into the Updated Treatment Plans. |
715.24(3) LICENSURE Narcotic detoxification
If a narcotic treatment program provides narcotic detoxification services, the narcotic treatment program shall develop and implement narcotic detoxification policies and procedures which include the following:
(3) A 1-year physiologic dependence is not required for narcotic detoxification although documentation of current dependency is required.
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Observations
Based on record reviews, the facility failed to ensure proper documentation of current dependency in one of two patient records reviewed, # 2.
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Plan of Correction
1. The Narcotic Treatment Physicians will document evidene of current physiologica dependence andat least a one-year history of physiological dependence (when applicable for maintenance treatment)on the Physician Documentation of Opiate Addiction form.
2. If a positive urine drug screen from a certified laboratory is not yet available at the time of assessment, the NTP will not check off Positive UDS for Opiates on the Documentation of Opiate Addiction form. Instead, the NTP will cite other evidence available at the time of assessment.
3. In such cases, the Positive UDS for Opiates will be checked off at the time results are available from a certified labortatory. The NTP will initial and date the entry on the form upon receipt of results from a certified laboratory.
4. The NPT in extreme cases will seek an exception to the requirement of current physiologic dependence through the Pennsylvania Department of Health, Division of Drug and Alcohol Program Licensure.
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