INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use narcotic agents, specifically methadone and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on August 24 - 25, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Innovative Recovery Solutions, Inc. was found not to be compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and a plan of correction is due on September 15, 2010.
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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 an interview with the project/facility director, the facility failed to document an informed and voluntary consent from the patient for the disclosure of information contained in the patient record, in 10 of 10 patient records, as required.
The findings include:
Ten patient records were reviewed on August 24 - 25, 2010. Ten patient records were required to include an informed and voluntary consent to release patient identifying information. Per regulation, 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). Ten patient records included consents to release information that included a revocation statement. This revocation statement indicated that the consent could be revoked upon the patient's written request. This is in violation of 42 CFR 2.31 which states a consent is subject to revocation at any time except to the extent that the program or person which is to make the disclosure has already acted in reliance on it. Per regulation, the consent to release information can be revoked by the patient in writing or verbally. The facility failed to provide the patients with an informed and voluntary consent including this revocation statement in patient records # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10. The facility released patient information that exceeded the limits imposed by 4 Pa. Code 255.5 in patient record # 4.
Patient # 4 was admitted to the program on April 1, 2010. On June 10, 2010 a letter was sent to the probation officer which released the results of urine tests and the information of the patient's current dosage of methadone. This exceeded the limits imposed by 4 Pa. Code 255.5.
The project/facility director was interviewed on August 25, 2010. The project/facility director reviewed the consents and confirmed that the revocation statement was incorrect. The project/facility director also confirmed the letter sent to the probation officer of patient
# 4 included information that exceeded 4 Pa. Code 255.5.
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Plan of Correction
Facility Director will remove the "in writing" statement from all revocation statements on our forms. Facility Director will provide in house training related to the limitations of 255.5 as related to release of information from patient's records. Documentation of this training will be maintained as part of each employee's record. Facility Director will ensure on-going compliance by training each new staff member and maintaining the documentation. |
715.16(b)(1-8) LICENSURE Take-home privileges
(b) The narcotic treatment physician shall consider the following in determining whether, in exercising reasonable clinical judgment, a patient is responsible in handling narcotic drugs:
(1) Absence of recent abuse of drugs (narcotic or non-narcotic), including alcohol.
(2) Regular narcotic treatment program attendance.
(3) Absence of serious behavioral problems at the narcotic treatment program.
(4) Absence of known recent criminal activity.
(5) Stability of the patient 's home environment and social relationships.
(6) Length of time in comprehensive maintenance treatment.
(7) Assurance that take-home medication can be safely stored within the patient 's home.
(8) Whether the rehabilitative benefit to the patient derived from decreasing the frequency of attendance outweighs the potential risks of drug diversion.
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Observations
Based on a review of patient records and an interview with the project/facility director, the facility failed to consider the criteria for take-home privileges in one of two patient records, as required.
The findings include:
Ten patient records were reviewed on August 24 - 25, 2010. Two patient records were reviewed for compliance with the regulations regarding take-home medications. Per regulation, the narcotic treatment physician shall consider the following in exercising reasonable clinical judgment, a patient is responsible in handling narcotic drugs: absence of recent abuse of drugs (narcotic or non-narcotic), including alcohol, regular narcotic treatment program attendance, absence of serious behavioral problems at the narcotic treatment program, absence of known recent criminal activity, stability of the patient 's home environment and social relationships, length of time in comprehensive maintenance treatment. assurance that take-home medication can be safely stored within the patient 's home, and whether the rehabilitative benefit to the patient derived from decreasing the frequency of attendance outweighs the potential risks of drug diversion. The facility failed to consider the criteria for take-home privileges in patient records # 1.
Patient # 1 was admitted into treatment on April 1, 2010. Patient # 1 transferred into treatment from another narcotic treatment program and was immediately granted take-home privileges. There was no documentation that the criteria had been considered for take-home privileges in patient record # 1.
The project/facility director was interviewed on August 25, 2010. The project/facility director reviewed patient record # 1 and confirmed that there was no documentation that the criteria had been considered prior to granting take-home privileges.
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Plan of Correction
Medical Director will consider the CSAT 8 point criteria before issuing any take home doses of medication for patients who transfer to our facility. Documentation will be maintained as part of the patient's permanent medical record and Facility Director will monitor for compliance through random chart audits. |
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 and an interview with the project/facility director, the facility failed to document an average of 2.5 hours of psychotherapy per month during the patient's first two years, in one of six patient records, as required.
The findings include:
Ten patient records were reviewed on August 24 - 25, 2010. Six patient records were reviewed for the completion of an average of 2.5 psychotherapy hours per month. Four patients had not attended treatment long enough to review the 2.5 hours of psychotherapy. Per regulation, 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. The facility failed to document an average of 2.5 hours of psychotherapy per month in patient record # 3.
Patient # 3 was admitted into treatment on March 15, 2010 and was discharged on May 27, 2010. The patient attended 1.75 hours of psychotherapy in March, 1 hour of psychotherapy in April and 2 hours of psychotherapy in May. Patient # 3 attended an average of 1.58 hours of psychotherapy per month.
The project/facility director was interviewed on August 25, 2010 and confirmed patient # 3 did not attend an average of 2.5 psychotherapy hours per month.
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Plan of Correction
Clinical staff will monitor each patient on their case load for compliance with the minimum counseling time each month and will provide patient reminders to assist with compliance. Each counselor will ensure that each patient on their case load receives their counseling time based on length of time in treatment. Facility Director will monitor for compliance through random chart audits. |
715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
Based on a review of patient records and an interview with the project/facility director, the facility failed to document the results of laboratory tests in three of ten patient records, as required.
The findings include:
Ten patient records were reviewed on August 24 - 25, 2010. Ten patient records were reviewed for the results of laboratory tests; specifically a tuberculosis Mantoux test (PPD). Per regulation, each patient file shall include the results of laboratory tests or other special examinations given by the narcotic treatment program. The facility failed to document the results of a Mantoux test in patient records # 1, 9 and 10.
Patient # 1 was admitted into treatment on April 1, 2010. There was no documentation of the results of a Mantoux test in patient record # 1.
Patient # 9 was admitted into treatment on April 9, 2010 and discharged on June 21, 2010. There was no documentation of the results of a Mantoux test in patient record # 9.
Patient # 10 was admitted into treatment on April 22, 2010 and discharged on May 31, 2010. There was no documentation of the results of a Mantoux test in patient record # 10.
The project/facility director was interviewed on August 25, 2010. The project/facility director confirmed the facility did not conduct a Mantoux test for patients # 1, 9 and 10. The project/facility director reported that the facility is now providing Mantoux tests for all current patients.
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Plan of Correction
As noted in the deficiency statement, Medical Staff have been performing TB testing on patients. Facility has corrected this issue and Facility Director will monitor through random chart audits for continued compliance. |
715.23(d)(1) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(1) The treatment plan shall identify the behavioral tasks a patient shall perform to complete each short-term goal.
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Observations
Based on a review of patient records and an interview with the project/facility director, the facility failed to document a treatment plan with long term treatment goals in four of eight patient records, as required.
The findings include:
Ten patient records were reviewed on August 24 - 25, 2010. Eight patient records included treatment plans which required long term treatment goals. Two patient records were new admissions and treatment plans were not yet due. Per regulation, a narcotic treatment program shall prepare a treatment plan that outlines realistic short and long term treatment goals which are mutually acceptable to the patient and the narcotic treatment program. The facility failed to document long term treatment goals in patient records # 1, 3, 8 and 9.
Patient # 1 was admitted into treatment on April 1, 2010. A treatment plan was completed on April 3, 2010. The treatment plan did not include long term treatment goals.
Patient # 3 was admitted into treatment on March 15, 2010. A treatment plan was completed on March 16, 2010. The treatment plan did not include long term treatment goals.
Patient # 8 was admitted into treatment on July 13, 2010. A treatment plan was completed on July 16, 2010. The treatment plan did not include long term treatment goals.
Patient # 9 was admitted into treatment on April 9, 2010 and discharged on June 21, 2010. A treatment plan was completed on April 9, 2010. The treatment plan did not include long term treatment goals.
The project/facility director was interviewed on August 15, 2010 and confirmed the treatment plans did not include long term goals.
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Plan of Correction
Clinical staff will work with each patient to formulate long terms goals as related to their personal progress in recovery and will document these goals in the patient's treatment plan. Facility Director will monitor for compliance through random chart audits. |
715.26(b) LICENSURE Security
(b) Each narcotic treatment program shall provide the Department with a specific plan describing the efforts it will make to avoid disruption of the community by its patients and the actions it will take to assure responsiveness to the community. This plan shall designate a staff member to act as community liaison.
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Observations
Based on a review of administrative policy and procedure and staff interviews, the facility failed to document a plan describing the efforts it will make to avoid disruption of the community by its patients and the actions it will take to assure responsiveness to the community.
The findings include:
The administrative policy and procedure manual was reviewed on August 24, 2010. Per regulation, each narcotic treatment program shall provide the Department with a specific plan describing the efforts it will make to avoid disruption of the community by its patients and the actions it will take to assure responsiveness to the community. This plan shall designate a staff member to act as community liaison. The policy and procedure manual included a policy that stated the facility would develop a plan for the community and designated the business manager as the community liaison. The project/facility director and business manager were interviewed on August 24 and 25, 2010 and reported they could not locate the community plan.
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Plan of Correction
Business Manager will complete documentation of all pre-opening activities which were completed to ensure a non-disruptive presence in the community. Additionally, a comprehensive plan will be formulated and presented to the Board of Directors at their next annual meeting which takes place in October. The approved plan will be kept on file for review and updated at least annually by the designated community liaison the Business Manager. The plan and Board of Director's approval will be completed by October 31, 2010 and the Facility Director will monitor for ongoing compliance. |