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 January 9, 2012 through January 11, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Aldie Foundation, 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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715.6(a)(2) LICENSURE Physician staffing
(a) A narcotic treatment program shall designate a medical director to assume responsibility for administering all medical services performed by the narcotic treatment program.
(2) When a narcotic treatment program is unable to hire a medical director who meets the qualifications in paragraph (1), the narcotic treatment program may hire an interim medical director. The narcotic treatment program shall develop and submit to the Department for approval a training plan for the interim medical director, addressing the measures to be taken for the interim medical director to achieve minimal competencies and proficiencies until the interim medical director meets qualifications identified in paragraph (1)(i), (ii) or (iii). The interim medical director shall meet the qualifications within 36 months of being hired.
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Observations
Based on a review of the administrative documentation that presented the qualifications of the interim medical director, the facility failed to submit the training plan for the interim medical director to the Department, as required.
The findings include:
The qualifications of the interim medical director were reviewed on January 9, 2012. The interim medical director was hired in October 2011 and the facility failed to provide documentation of the required training plan for the interim medical director.
The program coordinator was interviewed on January 9, 2011 and confirmed that the training plan was not submitted to the Department. A training plan was developed while licensing specialists were conducting the inspection.
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Plan of Correction
The training plan for the interim medical director has been submitted to the Department and was approved. The clinical director will monitor the plan's implementation and completion by the interim medical director. |
715.9(b)(3)(i-ii) LICENSURE Intake
(b) Exceptions to the requirements in subsection (a) are:
(3) A patient who has been treated and later detoxified from comprehensive maintenance treatment may be readmitted to maintenance treatment, without evidence to support findings of current physiologic dependence, up to 2 years after discharge, if the following conditions are me:
(i) The narcotic treatment program attended is able to document prior narcotic drug comprehensive maintenance treatment of 6 months or more.
(ii) The admitting narcotic treatment physician, exercising reasonable clinical judgment, finds readmission to comprehensive maintenance treatment to be medically justified.
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Observations
Based on the review of patient records, the facility failed to document the justification for admission without current dependence in one patient record.
The findings include:
Twenty-six patient records were reviewed on January 9, 2012 through January 11, 2012. One patient record was reviewed for readmission documentation of the justification for admission to the program after being discharged from the program.
Patient # 17 was re-admitted December 16, 2011. The patient's urine drug screens on December 1, 2011 and December 5, 2011 were negative for all substances. The patient had a drug screen on December 13, 2011 and was positive for buprenorphine. The patient was dosed at 20 mg of methadone on December 16, 2011 without medical documentation of current dependency from the narcotic treatment physician.
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Plan of Correction
The program coordinator has reviewed with the program physician the requirements regarding medical documentation of current dependency for both new admissions and readmissions. The program coordinator will monitor the physician's compliance and appropriate documentation of current dependence via quality reviews of client records. |
715.9(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
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Observations
Based on the review of patient records, the facility failed to contact the previous narcotic treatment facility for the patient's treatment history in two of two patient records reviewed.
The findings include:
Twenty-six patient records were reviewed January 9, 2012 through January 11, 2012. The reviews of these records revealed that two patients had histories of prior narcotic treatment.
Patient records # 10 and 16 contained documentation that patients # 10 and 16 had received narcotic treatment services previously at other narcotic treatment programs. The facility failed to document any attempt to obtain a patient's prior treatment history from the previously attended narcotic treatment facilities.
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Plan of Correction
The clinical director has reinforced with the program coordinator that, when the coordinator is conducting the screening/orientation session, the coordinator is to be sure to obtain the client's consent to obtain the records from any prior NTP attended; and to include copies or other documentation in the client record of such requests being made to the NTP(s) for the treatment records. The coordinator shall verify this being done and documented via the quality reviews of NTP client records. |
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 the review of patient records, the facility failed to demonstrate the physician made the determination of the patient's dose in four of seven patient records.
The findings include:
Twenty-six patient records were reviewed on January 9, 2012 through January 11, 2012. Patient records were reviewed for physician's documentation of the patient's initial and subsequent dose and schedule. The doctor documented "build up" orders during induction in patient records # 1, 8, 16, and 21.
Patient # 1 was admitted 7/7/2011. A standard order was used to order the initial dose and then the increases were left for the nursing staff to implement during the induction phase. The physician's order indicated a build-up order as follows: 7/8/2011-30 mg, 7/12/11-40 mg,7/16/11-50 mg, 7/20/11-60 mg.
Patient # 8 was admitted October 6, 2011. A standard order was used to order the initial dose and then the increases were left for the nursing staff to implement during the induction phase. The patient received their initial dose of 30 mg on 10/6/11. The physician's order indicated a build-up order written on October 18, 2011, 10/19/11- 40 mg, 10/23/11-50 mg, 10/27/11-60 mg.
Patient # 16 was admitted October 7, 2011. A standard order was used to order the initial dose and then the increases were left for the nursing staff to implement during the induction phase. The patient received their first dose of 30 mg on 10/7/2011. The physician's order indicated a build-up order as follows: 10/11/11- 40 mg, 10/15/11- 50 mg, 10/19/11- 60 mg.
Patient # 21 was admitted September 21, 2011. A standard order was used to order the initial dose and then the increases were left for the nursing staff to implement during the induction phase. The physician's order indicated a build-up order as follows: 9/21/11-40 mg, 9/24/11- 50 mg.
This finding was confirmed by the Program Coordinator.
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Plan of Correction
The physician who failed to comply with the facility's policy and procedure that banned the use of build-up orders is no longer employed by the facility. The replacement physician has been informed regarding this policy and procedure. The program coordinator will monitor the replacement physician's compliance, and appropriate documentation of initial and subsequent dose changes via quality reviews of client records. |
715.16(e) LICENSURE Take-home priveleges
(e) With an exception granted under subsection (d), a narcotic treatment program may not permit a patient to receive more than a 2-week take-home supply of medication.
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Observations
Based on the review of patient records, the facility granted more than a two-week supply of take-home medication by exception without Department approval.
The findings include:
Twenty-Six patient records were reviewed on January 9, 2012 through January 11, 2012. Patient # 6 had a take-home medication privilege change request form reviewed. The doctor had granted this patient a 15 day take home on 7/28/2011. The patient received fifteen days worth of take-home medication which exceeded the two-week supply permitted by the Department.
The Program Coordinator confirmed this finding.
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Plan of Correction
The physician who failed to comply with the facility's policy and procedure regarding take-home medication exceptions is no longer employed by the facility. The replacement physician has been informed regarding this policy and procedure and the Department's limit on allowable take-home supply. The program coordinator will monitor the replacement physician's compliance, and appropriate documentation of exception requests and written take-home orders via quality reviews of client records. |
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 document annual case consultations in four of five patient records.
The findings include:
Twenty-six patient records were reviewed on January 9, 2012 through January 11, 2012. Seventeen patient records were reviewed for case consultation. Five records reviewed required annual case consultations. The facility failed to document an annual case consultation in patient records # 3, 6, 14 and 15.
Patient # 3 was admitted April 29, 2006. The last case consultation documented in this patient record was April 23, 2007.
Patient # 6 was admitted May 28, 2009. The last case consultation documented in this patient record was September 1, 2010.
Patient #14 was admitted May 26, 2005 and discharged on March 10, 2011. There was no documentation in this patient records for a case consultation for 2010.
Patient # 15 was admitted July 19, 2009. The last case consultation was documented on December 10, 2009.
A discussion with facility staff concerning annual case consultations confirmed this finding.
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Plan of Correction
The program coordinator has re-informed program staff about the case consultation requirements, and shall monitor the completion and documentation of case consultations within the required timeframes via quality reviews of client records. |
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 the review of patient records, the facility failed to document follow-up on three of four patient records.
The findings include:
Twenty-six patient records were reviewed on January 9, 2012 through January 11, 2012. Ten patient records reviewed were discharged records. Four patient records were reviewed for follow-up information. The facility failed to document follow-up in patient records # 2, 4, and 13.
Patient # 2 was admitted on September 29, 2007 and was transferred to another methadone clinic on May 3, 2011. As of the date of the inspection, the facility had not documented follow-up in this patient record. There was also no documentation from transferring program indicating that the patient had been admitted and dosed.
Patient # 4 was admitted on October 28, 2010 and was transferred to another methadone clinic on June 26, 2011. As of the date of the inspection, the facility had not documented follow-up in this patient record. There was also no documentation from transferring program indicating that the patient had been admitted and dosed.
Patient # 13 was admitted on May 21, 2010 and left against facility advice on May 6, 2011. There was no follow-up documentation in this patient record.
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Plan of Correction
The program coordinator has re-instructed the program's nurse manager of the requirement to document the confirmation of transferred clients being admitted and dosed by the other NTP. The program coordinator shall monitor compliance with transfer follow-up documentation requirements when signing-off on the client record discharge paperwork.
The office manager sends a follow-up letter to all discharged clients, and retains a copy of all letters sent. The program coordinator will monitor post-discharge follow-up documentation compliance via quality reviews of closed client records.
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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 facility documentation that included incident reports and patient records, the facility failed to provide documentation of incident reports that could post negative community reaction and drug related hospitalization of a patient to the Department.
The findings include:
During the January 9, 2012 through January 11, 2012 methadone monitoring, the facility had documentation of incident reports that identified police being called to the facility on different occasions, as well as, a patient needed to be transported to the emergency room for an overdose.
An incident report involving patient #24 was reviewed on January 9, 2012. This incident involved facility staff calling the police regarding this patient. When the facility nurse arrived at the program on 10/3/2011, items of this patient were found on the front steps. There was a small plastic bag with residue that the police identified as cocaine. The police were called to the facility and told facility staff to contact them if the patient showed back up. The patient did show up to dose and the facility staff contacted the police. The patient met with the police and did not appear impaired. The patient did admit to cocaine use. This incident could have had a negative community reaction and should have been reported to the Department. There was no documentation that this incident was reported to the Department.
An incident report that involved patient # 25 was reviewed on January 9, 2012. This incident involved facility staff contacting the police regarding the patient's behavior. This incident could have had a negative community reaction and should have been reported to the Department. There was no documentation that this incident was reported to the Department.
An incident report that involved patient # 27 was reviewed on January 9, 2011. This incident involved patient # 27 being involved in an auto accident after dosing. People were injured in the accident. This incident could have had a negative community reaction and should have been reported to the Department. There was no documentation that this incident was reported to the Department.
An incident report that involved patient # 28 was reviewed on January 9, 2011. This incident involved patient # 28 being transported to the Emergency Room for a drug related overdose. There was no documentation that this incident was reported to the Department.
A discussion with facility staff confirmed that the facility was aware of the requirement to notify the Department of unusual incidents.
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Plan of Correction
The executive director has reiterated with the program coordinators that copies of reports are to be sent to the Department when an incident meets certain specified criteria, including the potential for negative community reaction. The facility's management team reviews all incident reports at its weekly meetings, and the operations director shall ensure that copies of incident reports are being sent to the Department as warranted and required. |