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 15, 2014, through January 16, 2014, by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the findings of the on-site inspection, Kensington Hospital Outpatient Treatment Program 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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715.11 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 and administrative documentation, the facility failed to adhere to 4 Pa Code 255.5 and 709.28 in one of five records.
The findings included:
Eight patient records were reviewed during the on-site monitoring visit. Five patient records were reviewed for confidentiality compliance. Additionally, the facility grievance documentation was reviewed.
Patient record # 17 -- The facility documented a disclosure in response to a grievance to a funding source that included information of the patient's medication level. This information exceeds that permitted by 4 Pa Code 255.5 and 709.28.
This is a repeat deficiency from the August 8, 2012, February 28, 2013, and August 8, 2013 monitoring visits.
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Plan of Correction
Our policy states that a patient's medication level shall not be disclosed to a funding source. A letter was sent was to the Director of Behavioral Health Servcies addressing this issue. All grievance responses will be reviewed by Administration effective 3/3/14. |
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 patient records, the facility failed to ensure the completion of random urine drug screens in three of eight records.
The findings included:
Eight patient records were reviewed during the on-site monitoring visit. All records were reviewed for monthly urine drug screens. Three records did not include documented monthly urine drug screens, # 12, 13 and 14.
Patient record # 12 was reviewed for the prior four months of urine drug screens. The facility failed to document a random monthly drug screen for September 2013.
Patient record # 13 was reviewed for the prior four months of urine drug screens. The facility failed to document a random monthly drug screen for December 2013.
Patient record # 14 was reviewed for the prior four months of urine drug screens. The facility failed to document a random monthly drug screen for December 2013.
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Plan of Correction
The Program Assistant will review all Urine Drug Screens (UDS) on the 15th of each month to insure a drug screen is done on all clients monthly. This log will then be monitored by the Director of Behavioral Health Services on a monthly basis to insure future compliance. |
715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on a review of patient records, the narcotic treatment physician failed to document the dosage levels were reviewed at least twice a year in one of six records
The findings included:
Eight patient records were reviewed during the on-site monitoring visit. Six records were reviewed for documentation of the narcotic treatment physician's review of the patient's dosage level.
Patient record #17 revealed the narcotic treatment physician conducted a dosage review on October 11, 2012 and on November 7, 2013. There were no other dose reviews during the twelve months.
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Plan of Correction
All clients are scheduled for the doctor for their dosage review twice a year. The Program Assistant will track appointments for doage levels and assure the appointment was kept or re-scheduled. The Program Assistant will keep a log of all clients, when they are due for their dosage review and if the appointment was kept effective 3/3/14. The Director of Behavioral Health will check the log quarterly for six (6) months to assure that dosage reviews are done on every client twice a year. This will be added to our Performance Improvement monitors. |
715.16(c)(1)(i-iv) LICENSURE Take-home privileges
(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:
(1) A narcotic treatment program may permit a patient to reduce attendance at the narcotic treatment program for observation to three times weekly and receive no more than a 2-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 3 months.
(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 patient records, the facility failed to include documentation in the patient record of the schedule for reduced attendance in one of one patient record.
The findings included:
Eight patient records were reviewed during the on-site monitoring visit. One patient record was reviewed for documentation of reduced attendance of no more than a 2-day take-home.
Patient record # 11 documented that reduced attendance was granted for observation to three times weekly. The record contained no documentation of the schedule for the take-home doses by the narcotic treatment physician.
The findings were reviewed with the Project Director, Medical Director and Facility Director and were not disputed.
This is a repeat deficiency from the monitoring visit on February 28, 2013 and August 8, 2013.
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Plan of Correction
A take home form will be developed for the Narcotic Treatment Physician (NTP) to address all the requirements for a patient to receive take home medication which will include documentation with the counselor, patient and physician, as well as the schedule for take home doses. The Program Assistant will review take home forms and initial to insure they are complete. The Director of Behavioral Health will check every new take home candidate to assure future compliance. |
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 provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment in one of four records.
The findings included:
Eight patient records were reviewed during the on-site monitoring visit. Four patient records were reviewed for psychotherapy hours during the first 2 years of treatment.
Patient record # 14 documented an admission date of October 31, 2013. The record did not contain any documented progress notes from October 31, 2013 to December 12, 2013.
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Plan of Correction
A take home form will be developed for the Narcotic Treatment Physician (NTP) to address all the requirements for a patient to receive take home medication which will include documentation with the counselor, patient and physician, as well as the schedule for take home doses. The Program Assistant will review take home forms and initial to insure they are complete. The Director of Behavioral Health will check every new take home candidate to assure future compliance. |
715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. 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 ensure provision of at least one hour of psychotherapy per month for one of one patient record.
The findings included:
Eight patient records were reviewed during the on-site monitoring visit.
Patient record # 17 documented an admission date of February 17, 2010, and a discharge date of December 18, 2013. The record contained a session documented for one-half hour on October 9, 2013. There were no further documented sessions for at least one-half hour in length for October 2013, November 2013, and December 2013.
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Plan of Correction
A tracking system has been developed to guarantee that all clients in need of treatment attend their scheduled sessions. This will be the responsibility of the Program Assistant and the Director of Behavioral Health Services will insure compliance by reviewing the tracking log system on a monthly basis. |
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 patient records, the facility failed to transfer the required patient files in one of one patient record.
The findings included:
Eight patient records were reviewed during the on-site monitoring visit.
Patient record # 17 documented an admission date of February 17, 2010, and a discharge date of December 18, 2013, as a transfer. There was no documentation of the required patient files being transferred to the receiving facility.
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Plan of Correction
It the responsible of the Program Assistant to document the transfer of any client files to another facility. An in-service will be given to all pertinent staff by the Director of Behavioral Health Services regarding the proper policy and procedure on documentation of transfers. This in-service will be included in the 3/3/14 training. The Director of Behavioral Health will review all transfered cases. |
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 administrative documentation, the facility failed to notify the patient in writing of involuntary termination in one of one patient record.
The findings included:
Eight patient records were reviewed during the on-site monitoring visit. The policy and procedure for involuntary termination was reviewed. The procedure for involuntary termination includes the staff notifying the patient of the reasons for discharge in writing.
Patient record # 17 documented an admission date of February 17, 2010, and a discharge date of December 18, 2013. There was no documentation of the patient being informed by facility staff of the reasons for involuntary termination.
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Plan of Correction
The Counselor of any client recommended for involuntary termination will alert the Director of Behavioral Health Services of such a situation. The Director of Behavioral Health Services will insure clients are made aware of any involuntary termination in writing when the need arises. |
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 the review of patient records, the facility failed to ensure the psychosocial evaluations were a clinical assessment of the historical data collected in one of eight patient record.
The findings included:
Eight patient records were reviewed during the on-site monitoring visit.
Patient record # 14 documented an admission date of October 31, 2013. The psychosocial evaluation was a repeat of patient history and failed to include a clinical assessment.
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Plan of Correction
There is a clinical staff training set for 2-28-14 that will aid in improving the quality of the PIR's Bio Psycho Social assessment.It will be the responsibility of the Director of Behavioral Health Service to make sure that the Psych Assessment is not a repetition of the history but rather an assessment derived from the history. The Director of Behavioral Health will conduct random monthly charts to insure future compliance. |
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 facility failed to document a discharge summary with all of the required information in two of four patient records.
The findings included:
Eight patient records were reviewed during the on-site monitoring visit. Four patient records were reviewed for discharge summaries. Two records failed to include all of the required components, # 17 and 18.
Patient record # 17 documented an admission date of February 17, 2010, and a discharge date of December 18, 2013. The discharge summary identified the reason for admission as opiate dependence. As this is a narcotic treatment program that only accepts opiate dependent patients, this reason is not individualized. Additionally, the discharge summary did not identify the patient's status upon discharge.
Patient record # 18 documented an admission date of March 22, 2012, and a discharge date of December 18, 2013. The discharge summary identified the reason for admission as "walk in." Additionally, the discharge summary did not identify the patient's response to treatment and status upon discharge.
This is a repeat deficiency from the August 8, 2012, February 28, 2013, and August 8, 2013 monitoring visits.
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Plan of Correction
A training has been scheduled for 2-28-14 to review the proper completion of a discharge summary. The discharge summaries will be individualized and specific as to why the client presents for treatment. Random monthly chart reviews will be done by the Director of Behavioral Health Services to insure discharge summaries are individualized and specific to the client. |
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 of patient records and administrative documentation, the facility failed to provide documentation of incident reports involving patient distribution of illicit substances near the facility to the Department.
The findings included:
During the onsite methadone monitoring review, the facility provided documentation of an incident that identified patient distribution of illicit substances near the facility. The facility failed to provide the Department with a written report that provided an account of the patient distribution of illicit substances with the potential for negative community reaction.
This is a repeat deficiency from the August 8, 2013, monitoring visit.
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Plan of Correction
In accordance with State regulations, the unusual incident reporting procedure will be discussed at the staff meeting 2/28/14. The definition of unusual incidents will be distributed to all staff members as a reminder. The Program Director will review all unusual incidents to insure the State is notified within 48 hours. |