INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on March 30, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site complaint investigation, JF Kennedy Community MH/MR 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 investigation and a plan of correction is due on April 30, 2011.
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Plan of Correction
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715.15(f) LICENSURE Medication dosage
(f) The narcotic treatment program shall develop written policies and procedures relating to narcotic treatment medication dosage which includes the requirements of subsections (a)--(e).
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Observations
Based on a review of the facility's policy and procedure and a review of patient records, the facility failed to follow their policy and procedure regarding the review of patient drug screen urinalysis results.
The findings include:
A review of the facility's policy and procedure for patient urine testing as well as a review of six patient records was completed on March 31, 2011. The policy and procedure stated that drug screen urinalysis results would be reviewed with patients within 48 hours of receipt.
The facility provided methadone medication to their patients and this medication is expected to be identified as "positive" in a drug screen urinalysis as it is administered daily to a patient. This review identified that patient drug screen urinalysis results identified "negative" for methadone in the patient records reviewed. The facility failed to provide documentation that the negative drug screen results for methadone were addressed with the patient in six of six patient records.
Patient # 1 had a drug screen urinalysis with results that indicated negative for methadone on 1/10/2011. There was no documentation in the patient records that identified that this result was reviewed with the patient.
Patient # 2 had a drug screen urinalysis that was negative for methadone on 3/3/2011. There was no documentation in the patient records that identified that this result was reviewed with the patient.
Patient # 3 had a drug screen urinalysis results that was negative for methadone on on 9/01/2010 and 11/03/2010. There was no documentation in the patient records that identified that these results were reviewed with the patient.
Patient # 4 had a drug screen urinalysis that was negative for methadone on 1/06/2011. There was no documentation in the patient records that identified that this result was reviewed with the patient.
Patient # 5 had drug screen urinalysis results that were negative for methadone on 1/11/2011, 2/09/2011 and 2/24/2011. Documentation in the patient revealed that the counselor addressed the urine drug screen results following the second negative drug screen urinalysis but failed to follow-up with the third result and a documentation of a plan to address the results.
Patient # 6 had drug screen urinalysis that was negative for methadone on 1/13/2011 and 3/30/2011. There was no documentation in the patient records that identified that these results was reviewed with the patient.
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Plan of Correction
Effective April 26, 2011 counselor staff will review and document their discussion of urine drug screen results with their patients in a manner that is consistent with the Program's drug screen policy and procedure. The Clincal Supervisor is responsible for monitoring chart documentation to ensure compliance with this standard.
Effective 5/18/2011, urine drug screens for patients that were negative for methadone have been reviewed with the patients and documented in patient records. In some instances, patients have received and signed-off on written memorandum regarding this issue. Corrective action has been taken in all cases. Counselor staff are instructed to be vigilant regarding this issue and to provide consistent follow-up. The Clinical Supervisor is responsible for monitoring of staff follow-up to ensure compliance with this standard.
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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 staff discussions, the facility failed to provide documentation of incident reports involving death to the Department.
The findings include:
During the March 31, 2011 complaint investigation, the facility had documentation of incident reports that identified patient deaths. Patients # 2 and 3 died while in treatment. The facility failed to provide the Department with written report that provided an account of the patient's death.
A discussion with facility director confirmed that the facility was aware of the requirement to notify the Department of patient deaths.
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Plan of Correction
Effective immediately, the Clinical Supervisor will be responsible for completing and forwarding an 'Unusual Incident Report' about patient deaths and other unusual incidents to the Division of Drug/Alcohol Program Licensing within 48 hour of program notification. The Project Director is responsible for ensuring compliance with this standard. |