INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection pertaining to the plans of correction for the February 4, 2014 methadone monitoring inspection. The follow-up inspection was conducted on September 2, 2014 by staff from the the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Polaris Renewal Services, 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 inspection.
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Plan of Correction
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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on the review of patient records, the facility failed to ensure that prior to the administration of an agent that the narcotic treatment physician documented in the patient's record the basis for the determination of current physiological dependency and evidence of a 1 year history of addiction in six of eight patient records.
The findings include:
Ten patient records were reviewed on September, 2014. Eight patient records required documentation of the narcotic treatment physician's basis for the determination of current physiological dependency and evidence of a 1 year history of addiction. The facility failed to include documentation of the narcotic treatment physician's basis for the determination of current dependency and evidence of a 1 year history of addiction, prior to the administration of an agent, in patient records # 2, 3, 5, 6, 8 and 10.
Patient # 2 was admitted on May 21, 2014. The patient's initial dose was given on May 21, 2014. There was no documentation of the physician's determination of current dependency and evidence of a 1 year history of addiction.
Patient # 3 was admitted on April 17, 2014. The patient's initial dose was given on April 17, 2014. The documentation of the physician's basis for the determination of current dependency and evidence of a 1 year history of addiction was signed by the physician on April 23, 2014.
Patient # 5 was admitted on July 8, 2014. The patient's initial dose was given on July 8, 2014. The documentation of the physician's basis for the determination of current dependency and evidence of a 1 year history of addiction was signed by the physician on July 15, 2014.
Patient # 6 was admitted on July 14, 2014. The patient's initial dose was given on July 15, 2014. There was no documentation of the physician's determination of current dependency and evidence of a 1 year history of addiction.
Patient # 8 was admitted on June 30, 2014. The patient's initial dose was given on June 30, 2014. The documentation of the physician's basis for the determination of current dependency and evidence of a 1 year history of addiction was signed by the physician on July 8, 2014.
Patient # 10 was admitted on April 21, 2014. The patient's initial dose was given on April 21, 2014. The documentation of the physician's basis for the determination of current dependency and evidence of a 1 year history of addiction was signed by the physician on May 14, 2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to ensure that prior to administration of an agent, the program's narcotic treatment physician shall make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The physician is responsible to determine and document in the patient's record determination of current dependency and evidence of a 1 year history of addiction on all patients. The receptionist is responsible for scheduling all new patients to see physician prior to any administration of any narcotic medication from the program. The nursing staff shall oversee that proper documentation of current dependency and former history of addiction has been notated by the program physician in the patient's medical chart. The facility director will be responsible to monitor compliance on an ongoing basis. |
715.20(4) 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.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on the review of patient records, the facility failed to notify the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program in four of six patient records.
The findings include:
Ten patient records were reviewed on September 2, 2014. Six patient records were reviewed for documentation of notification to the transferring facility of the admission and initial dose of the transferred patient. There was no documentation of the transferring narcotic treatment program being notified of the admission and initial dose given to the patient in patient records # 2, 5, 6, and 10.
Patient #2 was a transfer from another treatment facility and was admitted on May 21, 2014. The facility failed to document both the date the patient was admitted and the date of the patient's initial dose on the notification of transfer included in the record.
Patient # 5 was a transfer from another treatment facility and was admitted on July 8, 2014. The facility failed to document both the date the patient was admitted and the date of the patient's initial dose on the notification of transfer included in the record.
Patient # 6 was a transfer from another treatment facility and was admitted on July 14, 2014. The facility failed to document both the date the patient was admitted and the date of the patient's initial dose on the notification of transfer included in the record.
Patient # 10 was a transfer from another treatment facility and was admitted on April 21, 2014. The facility failed to document both the date the patient was admitted and the date of the patient's initial dose on the notification of transfer included in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to notify the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program in four of six patient records. The narcotic treatment program shall ensure that any patient transferred to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days shall document in writing that the receiving program notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient as the receiving narcotic treatment program. It is the responsibility of the receiving program physician to determine the appropriate dose and schedule for those patients and the receiving program nursing staff shall record the proper dose information and admission date which they shall be responsible for sending to the transferring clinic and thereafter retrieve a fax confirmation page for filing in the patient's medical chart. The facility director has provided training to both nursing staff and physician in this area. Ongoing compliance will be the responsibility of the facility director through regular review of medical records and ongoing consultation with nursing staff and medical director. The facility director will be responsible to monitor compliance on an ongoing basis. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on the review of patient records, the facility failed to document an annual evaluation of each patient's status, completed by the patient's counselor, and reviewed, dated and signed by the medical director in two of two patient records.
The findings include:
Ten patient records were reviewed on September 2, 2014. Two patient records required documentation of an annual evaluation by the patient's counselor. The facility failed to document an annual evaluation in patient records # 7 and 9.
Patient # 7 was admitted on July 9, 2013. An annual evaluation completed on July 25, 2014 did not address the patient's legal standing, financial management abilities' physical and emotional health, fulfillment of treatment objectives, fulfillment of treatment objectives nor the patient's employment, education and training. The evaluation was not dated and signed by the medical director.
Patient # 10 was admitted on April 21, 2013. An annual evaluation completed on August 6, 2014 did not address the patient's legal standing, financial management abilities' physical and emotional health, fulfillment of treatment objectives, fulfillment of treatment objectives nor the patient's employment, education and training. The evaluation was not dated and signed by the medical director.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to document an annual evaluation of each patient's status, completed by the patient 's counselor, and reviewed, dated and signed by the medical director in two of two patient records. Staff in service training was conducted by the facility director on 09/03/14 to review policy 715.23(c)(1-7) and procedure for completing annual evaluations. Ongoing compliance will be the responsibility of the facility director and will be monitored through daily individual record review and weekly clinical supervision. Ongoing in service trainings will occur as needed to ensure ongoing compliance. |