INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on March 3 and 4, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site complaint investigation, Tadiso, Inc 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 28, 2009.
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Plan of Correction
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709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of patient records, the facility's written policy and procedure on disciplinary action and involuntary detoxification, the facility's grievance log and the incident report log, the facility failed to properly revise its written policy and procedure on disciplinary action and involuntary detoxification to reflect the procedures agree to in the Settlement Agreement between the Department of Health and the facility dated March 13, 2008. The facility's policy and procedure failed to include a directive stating that the facility shall not conduct or permit the involuntary detoxification of such patients until patient specific approval was provided by the Department, as agreed to in Paragraph 1 of the Settlement Agreement. The initiation of involuntary detoxification was documented in 7 of 22 patient records reviewed on March 3 and 4, 2009 where the patients had filed grievances appealing the facility's decision to involuntarily terminate the patients from treatment and initiate involuntary detoxification, and where there was no evidence that patient specific approval had been provided by the Department or that the facility ceased the involuntary detoxification of the patient pending a response from the Department.
The findings include:
Patient record #2 - A review of the patient's record on March 3, 2009, revealed that on November 24, 2008, the patient was given written notice of involuntary termination of treatment. The notice stated the involuntary termination was based on the patient's violation of program rules. On November 24, 2008, the patient filed a grievance appealing the involuntary termination. The facility initially stayed the imposed penalties until January 1, 2009, pending resolution of the grievance, but later continued the patient's involuntary termination and imposed penalties including detoxification which commenced on January 1, 2009 and ended on January 29, 2009. There was no documentation in the patient record to demonstrate that the involuntary termination and detoxification was based on a history of acts of violence or threats to commit acts of violence in or around the facility. The patient was discharged on January 29, 2009.
There was no documentation in the patient record or in the facility's record that the facility sought or received specific approval to proceed with the involuntary detoxification of the patient. A review of records of the Division of Drug and Alcohol Program Licensure also did not reveal any request from the facility specific to the patient seeking authorization from the Department to proceed with the involuntary detoxification of the patient. The Department did not issue an authorization for the involuntary detoxification of this patient.
Patient record #4 - A review of the patient's record on March 3, 2009, revealed that on March 29, 2008, the patient was given written notice of involuntary termination of treatment. The notice stated the involuntary termination was based on the patient's violation of program rules. On March 29, 2008, the patient filed a grievance appealing the involuntary termination. Although required by subsection 715.22, the facility did not stay the patient's involuntary termination and imposed penalties on the patient including detoxification which commenced on March 29, 2008, and ended on April 4, 2008. There was no documentation in the client record to suggest that this was anything other than an involuntary detoxification and termination. The involuntary termination and detoxification was not based on a history of acts of violence or threats to commit acts of violence in or around the facility. The patient was discharged on April 4, 2008..
There was no documentation in the patient record or in the facility's record that the facility sought or received specific approval to proceed with the involuntary detoxification of the patient. A review of records of the Division of Drug and Alcohol Program Licensure also did not reveal any request from the facility specific to the patient seeking authorization from the Department to proceed with the involuntary detoxification of the patient. The Department did not issue an authorization for the involuntary detoxification of this patient.
Patient record # 6 - A review of the patient's record on March 3, 2009, revealed that on November 24, 2008, the patient was given verbal notice of involuntary termination of treatment during a case conference conducted on that date. The patient was given written notice of involuntary termination on December 3, 2008. The notice stated the involuntary termination was based on the patient's violation of program rules. On November 24, 2008, the patient filed a grievance appealing the involuntary termination. Although required by subsection 715.22, the facility did not stay the patient's involuntary termination and imposed penalties on the patient including detoxification which commenced on November 24, 2008, and ended on April 4, 2008. There was no documentation in the patient record to demonstrate that this was anything other than an involuntary detoxification and termination. The involuntary termination and detoxification was not based on a history of acts of violence or threats to commit acts of violence in or around the facility. The patient was transferred on December 3, 2008.
There was no documentation in the patient record or in the facility's record that the facility sought or received specific approval to proceed with the involuntary detoxification of the patient. A review of records of the Division of Drug and Alcohol Program Licensure also did not reveal any request from the facility specific to the patient seeking authorization from the Department to proceed with the involuntary detoxification of the patient. The Department did not issue an authorization for the involuntary detoxification of this patient.
Patient record # 8 - A review of the patient's record on March 4, 2009, revealed that during the week of March 21, 2008, the patient was given verbal notice of involuntary termination of treatment by her counselor. The notice stated the involuntary termination was based on the patient's violation of program rules. On March 29, 2008, the patient filed a grievance appealing the involuntary termination. The facility stayed the penalty until May 3, 2008, but then imposed the penalty again, in violation of subsection 715.22, by continuing with the involuntary termination with a detoxification which commenced on May 3, 2008, and ended on June 3, 2008. The detoxification was involuntary because the patient did not request the detoxification. The involuntary termination and detoxification was not based on a history of acts of violence or threats to commit acts of violence in or around the facility. The patient was discharged on June 3, 2008.
There was no documentation in the patient record or in the facility's record that the facility sought or received specific approval to proceed with the involuntary detoxification of the patient. A review of records of the Division of Drug and Alcohol Program Licensure also did not reveal any request from the facility specific to the patient seeking authorization from the Division to proceed with the involuntary detoxification of the patient. The Department did not issue an authorization for the involuntary detoxification of this patient.
Patient record # 12 - A review of the patient's record on March 4, 2009, revealed that on March 13, 2008, the patient was given written notice of involuntary termination of treatment. The notice stated the involuntary termination was based on the patient's violation of program rules. On March 17, 2008, the patient filed a grievance appealing the involuntary termination. The facility initially stayed the patient's involuntary termination including detoxification on March 17, 2008, holding the patient at the lower dose, but then at the order of the physician the detoxification was resumed and commenced on March 26, 2008. and ended on March 26, 2008. There was no documentation in the patient record to demonstrate that this was anything other than an involuntary detoxification and termination. The involuntary termination and detoxification was not based on a history of acts of violence or threats to commit acts of violence in or around the facility.
There was no documentation in the patient record or in the facility's record that the facility sought or received specific approval to proceed with the involuntary detoxification of the patient. A review of records of the Division of Drug and Alcohol Program Licensure also did not reveal any request from the facility specific to the patient seeking authorization from the Department to proceed with the involuntary detoxification of the patient. The Department did not issue an authorization for the involuntary detoxification of this patient.
Patient record # 17 - A review of the patient's record on March 4, 2009, revealed that on January 9, 2009, the patient was given verbal notice of involuntary termination of treatment. On January 9, 2009, the patient filed a grievance appealing the involuntary termination. The patient reported on the grievance that he was told the involuntary termination was based on the patient's violation of program rules. Although required by subsection 715.22, the facility did not stay the patient's involuntary termination and imposed penalties on the patient including detoxification which commenced on January 9, 2009, and ended on January 13, 2009. There was no documentation in the patient record to demonstrate that this was anything other than an involuntary detoxification and termination. The involuntary termination and detoxification was not based on a history of acts of violence or threats to commit acts of violence in or around the facility. The patient was discharged on January 13, 2009.
There was no documentation in the patient record or in the facility's record that the facility sought or received specific approval to proceed with the involuntary detoxification of the patient. A review of records of the Division of Drug and Alcohol Program Licensure also did not reveal any request from the facility specific to the patient seeking authorization from the Department to proceed with the involuntary detoxification of the patient. The Department did not issue an authorization for the involuntary detoxification of this patient.
Patient record # 18 - A review of the patient's record on March 4, 2009, revealed that on August 26, 2008, the patient was given verbal notification of involuntary termination of treatment. On August 26, 2008, the patient filed a grievance appealing the involuntary termination. The patient's grievance stated the involuntary termination was based on the patient's violation of program rules. The facility initially stayed the patient's involuntary termination until September 26, 2008 when it commenced at the order of the facility director. The detoxification which commenced on September 26, 2008, ended on October 1, 2008. There was no documentation in the patient record to demonstrate that this was anything other than an involuntary detoxification and termination. The involuntary termination and detoxification was not based on a history of acts of violence or threats to commit acts of violence in or around the facility.
There was no documentation in the patient record or in the facility's record that the facility sought or received specific approval to proceed with the involuntary detoxification of the patient. A review of records of the Division of Drug and Alcohol Program Licensure also did not reveal any request from the facility specific to the patient seeking authorization from the Department to proceed with the involuntary detoxification of the patient. The Department did not issue an authorization for the involuntary detoxification of this patient.
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Plan of Correction
Tadios Inc. did not inlcude the specifics of the agreement with the Department in its written policies. The Chief Administrative Officer will ensure that the Client Handbook and Social Service Operational procedures outline fully the notification to the Department regarding administrative withdrawals from the treatment facility. The process of administrative withdrwal for clients at Tadiso will be outlined in wirtten policy to clients and staff. Counseling staff will be instructed by the Social Service Director to follow the Department's procedure. Time frame is by May 15,2009 |
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 a review of patient records, the facility failed to document a physician's dosing order in one of 22 patient records.
The findings include:
Twenty two patient records were reviewed on March 4, 2009. Physician's dosing orders were required in all patient records. The facility failed to document dosing records in one of 22 patient records.. Patient # 12 received notice that he was being administratively discharged from treatment on March 13, 2008, the detoxification from methadone was started the next day. There was no documentation of a physician's order that specified a change in medication due to the administrative withdrawal.
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Plan of Correction
Physcian order was missing from a client file regarding change in medication dosage due to administrative withdrawal. Medical Director or Staff Physician is and will be present at all meetings with clients regarding medication changes. The medication order will be written . The Medical Co-ordinatior/Nursing Supervisor will check to ascertain that a written physician order for all dosage changes has been received prior to input in the computerized medication system. The Data Clerk under the direction of the Quality Assurance Co-ordinator will review files to ensure the documentation was properly filed. This will be a daily process. Timeframe is May 1, 2009 |
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 facility policy and a review of patient records, the facility failed to confine their reasons for termination to those reasons identified by Commonwealth regulation and Department of Health Directive in 7 of 22 patient records.
The findings include:
Facility policy identified that patients could be terminated for violations of facility regulations which included:
1. Verbal or physical abuse of staff or patients in or around facility premises to include a two block radius of the facility. Abuse is clarified to include use of profanity, yelling and threatening behavior.
2. Using, possessing or dispensing any drugs or exchanging money on agency premises or in the two block area surrounding the facility.
3. Loitering.
4. Failure to ingest medication under the observation of the nursing staff.
5. Continued use of illegal drugs.
6. Failure to keep appointments.
7. Lending or alteration of identification cards or take-home medication labels.
8. Possession of a weapon.
9. Failure to get an annual physical or allow coordination of treatment with a prescribing physician.
10. Failure to comply with facility regulations.
11. Alteration or destruction of take-home medication bottles.
12. Refusal to provide a urine sample
Patients # 13 and 16 were administratively discharged due to illicit drug use. Patient record # 12 contained documentation of a letter of involuntary detoxification and termination to the patient but the specific reasons for discharge were not cited in the letter. There was no documentation in these patient records demonstrating that the involuntary terminations were initiated only when all other efforts to retain the patient in the program had failed.
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Plan of Correction
Tadiso Inc. will change its policy regarding administrative terminations to relfect point by point the Department's patient termination regualtions. These revisions will be written in the procedure and policy manual for staff and in the client handbook. The Chief Administrative Officer and the Director of Social Serive will ensure the dissemination of the written policy and give staff instuctions. Counselors will get written verfication from clients that the policy was explained fully. Timeframe is May 15, 2009. |
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 patient records, the narcotic treatment program failed to document all efforts to retain the patient in the program prior to initiating an involuntary termination in eight of eight patient records.
The findings include:
Twenty two patient records were reviewed on March 4, 2008. Documentation that an involuntary termination was initiated only when all other efforts to retain the patient in the program have failed was required in eight patient records. The facility did not document the efforts made to retain a patient in treatment in patient records # 13, 15, 16, 17 and 18. The treatment plan and progress notes in these patient records failed to address any efforts to retain each of the patients in treatment. Documentation in the patient records identified reasons for termination but failed to specify what interventions, other than an opportunity to transfer to another treatment facility, were pursued prior to the termination of treatment. Further, patient records failed to document letters of termination for patients # 11, 14 and 18.
Additionally, the facility failed to confine reasons for the involuntary detoxification and termination of a patient's treatment to those reasons identified by this regulation. Patients # 13 and 16 were administratively discharged due to illicit drug use. Patient record # 12 contained documentation of a letter of involuntary detoxification and termination to the patient but the specific reasons for discharge were not cited in the letter. There was no documentation in these patient records demonstrating that the involuntary terminations were initiated only when all other efforts to retain the patient in the program had failed.
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Plan of Correction
Treatment alternatives and effotrs to maintain clients in treatment were not adequaltely documented.
Tadiso Inc. will review all clients and client files deemed non-compliant following the Department's regulations. Counselor and supervisor consultations will be required and documented courses of action will be outlined including referrals and/or revised treatment plans. Contingencies do and will include medication changes,increased counseling, and mental health referrals.Case Conferences will be scheduled with represntatives of Administration, Social Sevice and Medical personnel to meet with the client to discuss progress or regression on treatment goals. The Chief Administrative Officer will ensure that the process is adhered to and will be contacted by Social Service and Medical staff on cases of non-compliance.
This process will be in written form in the procedure manuals. Timeframe is May 1, 2009. |
715.22(c) LICENSURE Patient grievance procedures
(c) Penalties may not be initiated prior to final resolution with the exception that penalties may be initiated against patients who have committed acts of physical violence or who have threatened to commit acts of physical violence in or around the narcotic treatment program premises.
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Observations
Based on a review of patient records and facility documentation, the facility failed to stay penalties, including detoxification, pending resolution of the grievances following notification of termination in eight of eight patient records.
The findings include:
Twenty-two patient records were reviewed on March 3-4, 2009. The documentation in the patient records revealed there were eight patients who, when notified of the facility's intent to involuntarily terminate their treatment, filed grievances to appeal their involuntary detoxification and termination from treatment, specifically patients # 2, 4, 6, 8, 11, 12, 17 and 18. The facility began to impose penalties prior to the resolution of the grievances and contrary to the settlement agreement of March 13, 2008, between the facility and the Division of Drug and Alcohol Program Licensure (DAPL). The facility failed to withhold the initiation of penalties until resolution of the grievances and patient specific approval was provided by the Department of Health. The facility failed to request patient specific approval for termination from the Department relative to the actions taken against patients # 2, 4, 6, 8, 11, 12, 17 and 18, and in accordance with the regulations as modified by the Settlement Agreement of March 13, 2008.
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Plan of Correction
Tadiso Inc. will notify the Department upon receipt of grievances from clients who may be deemed non-compliant
and subject to administrative withdrawal from the facility. Client Handbook will clearly outline this process and no withdrawal will be initiated without the Department's input and approval. The written documentation will be in the operational manual as well. The Chief Administrative Officer and the Director of Social Service will ensure staff is instructed on this process. Clients will sign forms for verification of this policy change. Time frame is May 15, 2009. |