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 March 9-11, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Narcotic Addict Rehabilitation Program Of Thomas Jefferson University 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 and a plan of correction is due on April 8, 2011.
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Plan of Correction
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715.16(a)(1) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(1) A narcotic treatment program may give take-home medications only to a patient who the narcotic treatment physician has determined is responsible and able to handle narcotic drugs outside the narcotic treatment program.
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Observations
Based on a review of patient records, administrative documentation and discussions with administrative and medical staff, the facility failed to grant take home medications only to those determined to be responsible and able to handle narcotic drugs outside the narcotic treatment program.
The findings include:
Fifteen patient records were reviewed March 9-11, 2011. The administrative documentation of patients who had been discharged as non-compliant was reviewed March 10, 2011. Two patients records, # 14 and # 15, contained documentation of the physician writing an order for take home medication bottles to accommodate the managed care program finding them another narcotic treatment facility.
Patient #15 was administratively discharged on January 7, 2011 with five take home bottles. She was provided with the take home medication after being discharged due to physical
violence against another patient and a staff person at the facility. Patient # 14 was discharged as non-compliant with facility rules and failure to adhere to the treatment plan. The medical director approved two take home bottles until the managed care entity could obtain another narcotic treatment program for the patient.
In discussion with the medical director, the nursing director, the facility director and the clinical director, they reported they did not determine the patient's were responsible to have take home privileges, but rather followed the specific dictates of the funding source.
Facility staff reported they were instructed by the patients' funding sources to provide the patients with take-home medication. They also did not follow their own take home privilege policy, one that complied with state regulations.
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Plan of Correction
It will be the responsibility of the Medical Director and Program Coordinator to ensure that the policies and procedures surrounding take-home medications are properly enacted. Only those patients who are deemed by the progran physician(s) to be responsible to receive take-home bottles will be afforded this privilege. In those instances where an individual's acts of, or threats of violence render them a threat to the treatment community, limited on-site medicating privileges will be offered (assuming they are deemed unfit for take hime privileges) until alternate treatment options can be secured. |
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 and administrative documentation, the facility failed to document the attempt or completion of patient follow up contact in three of five patient records.
The findings include:
Fifteen patient records were reviewed March 9-11, 2011. The facility policy and procedure manual was reviewed March 9, 2011.
Five patient records were reviewed for follow-up documentation. Three patient records did not have the required documentation.
Patient # 6 was discharged December 23, 2010 and the patient's record did not have documentation of a follow-up attempt or contact with the patient.
Patient # 12 was discharged October 25, 2010 and the patient's record did not have documentation of a follow-up attempt or contact with the patient.
Patient # 13 was discharged September 28, 2010 and the patient's record did not have documentation of follow-up attempt or contact with the patient..
The facility's policy titled "Follow-up Information" stated:
"It is the policy that patients who are discharged from the program because of any reason other than being transferred or referred (e.g. treatment completion, AWOL) receive follow-up contact. Follow-up information is typically collected 60 days after discharge by means of a two page follow-up form."
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Plan of Correction
New policies and procedures with respect to follow-up were agreed upon in December, 2010. Specifically, at the time of discharge, administrative support personnel will make efforts to contact all former patients (other than those who are known to be deceased or incarcerated)for the purpose of administering a newly designed follow-up questionnaire. Success at contact efforts will be documented at this time. It will be the responsibility of the program coordinator to ensure that these actions are conducted as proposed. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of patient records, administrative documentation and an interview with the clinical supervisor, the facility failed to notify the patient, in writing, of a decision to involuntarily terminate the patient's treatment at the project, in four of four patient records.
The findings include:
Fifteen patient records were reviewed on March 9-11, 2011. Four patient records required notification to the patient, in writing, of a decision to involuntarily terminate the patient's treatment at the project. The facility failed to notify the patient, in writing, of a decision to involuntarily terminate the patient's treatment at the project, in patient records # 6, 7, 12 and 13.
Patient # 6 was discharged as non-compliant December 23, 2010. There was no written notification to the patient in the patient's record or the grievance/appeal folder.
Patient # 7 was discharged as non-compliant March 11, 2011. There was no written notification to the patient in the patient's record or the grievance/appeal folder.
Patient # 12 was discharged as non-compliant October 25, 2010. There was no written notification to the patient in the patient's record.
Patient # 13 was discharged as non-compliant September 28, 2010. There was no written notification to the patient in the patient's record.
The clinical supervisor was interviewed on March 10, 2011. The clinical supervisor reviewed the patient records agreed the letters of termination were not documented.
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Plan of Correction
Staff will be trained by the Program Coordinator and Senior Therapist about the need for informing patients in writing of an intent to involuntarily terminate treatment. As part of this training, staff will be reminded that each patient who is to be involuntarily terminated shall receive, when possible, written notification of this impending action. This notification shall come from the therapist and be signed by the patient indicating they have been offered and received a copy. In instances where the patient has absented themselves from the program, there will be an attempt made to mail a termination letter to the patient's address. No such efforts will be made if program personnel have been requested not to mail information to their address. It will be the responsibility of the Program Coordinator and/or Senior Clinician to ensure that these efforts are appropriately documented in the record of care. |