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 September 9 - 11, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHJ Medical Center Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on October 8, 2008.
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Plan of Correction
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715.9(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
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Observations
Based on a review of 14 patient records on September 10 and 11, 2008, the facility failed to document they contacted the previous narcotic treatment facility for the treatment history in one of two patient records where required.
Finding:
The facility did not document they contacted the previous narcotic treatment facility for the treatment history in patient record #9.
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Plan of Correction
An audit will be conducted by supervisory staff to assess the staff documentation of attempts to contact previous narcotic treatment providers. The project director will then hold a staff meeting to discuss the findings and remind staff that it is necessary to encourage clients to sign releases to enable better continuity of care. Staff will also be instructed on proper documentation if client refuses to allow contact. In order to ensure staff compliance intake documentation will be audited randomly by supervisory staff. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of 14 patient records on September 10 and 11, 2008, the facility failed to document a monthly urinalysis test for one of eight patient records where required.
Finding:
The facility failed to document a monthly urinalysis in patient record #14.
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Plan of Correction
To ensure future compliance all staff will meet with the project director and the staff will be instructed to document reciept of all urines for clients on each of their caseloads and one week prior to the end of the month each staff member will turn in a list of individual clients for whom they did not recieve urinalysis results to the nursing staff. The nursing staff will then schedule any clients who are not scheduled for urines. |
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 the 14 patient records, the facility failed to document that the physician made the dose changes in six of six patient records where required.
Finding:
The facility failed to document that the physician made the dose changes. There was no documentation of who authorized the changes in patient medication doses. The facility has a "dose adjustment/physician orders" form that is completed by staff other than the physician. In patient record # 8, a dose increase is documented for 3-20-08, but it is missing a physician signature. In patient records # 9, 10, 11, 12 and 14, the nurse documented the dose increase or decrease and the physician circled "approve" or "disapprove" and signed the order.
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Plan of Correction
The dosage adjustment form will be reviewed by the project director and medical director to determine how we will be able to more effectively document dosage adjustments made by the physician staff and the form will be adjusted accordingly. The new form will then be reviewed with all staff and instructions will be provided to ensure proper use of the form and continued compliance with the regulation. |
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 a review of the 14 patient records on September 10 and 11, 2008, the facility failed to document that the patient received a written notice of involuntary termination in one of two patient records where required.
Finding:
The facility did not document the patient received a written notice of the involuntary termination in patient record #1.
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Plan of Correction
The project director will conduct a meeting to review the discharge procedures and ensure that all future documentation is correct. Discharge Chart audits will then be conducted to ensure staff compliance. |
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 the 14 patient records on September 10 and 11, 2008, the facility failed to ensure that patients could not be discharged for any reasons other than those listed in the standards.
Finding:
All of the patient records included a Financial Responsibility Form that states, "Payments must be made by Wednesday of the current week or the client may be discharged from the program". Facilities are unable to discharge patients due to financial non-payment.
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Plan of Correction
The Financial responsiblity form will be reviewed and updated by the project director and the statement will be removed. |
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 14 patient records on September 10 and 11, 2008, the facility failed to document the results of the serological tests in one of seven patient records where required.
Finding:
The facility did not document the results of the blood work in patient record #12.
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Plan of Correction
The project director will provide a training with the nursing staff where a review of the bloodwork policies and procedures will be conducted. The counselors will then be instructed to review all documentation of any new clients to ensure that all intake documentation has been completed and is correct including reciept of bloodwork. |
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 a review of the unusual incident reports and a conversation with the director, the facility failed to notify the department of an incident within 48 hours.
Finding:
The facility failed to notify the department of a patient death, patient record #3, that occurred in July 2008.
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Plan of Correction
An Incident report was completed by the clinical supervisor and faxed to the department. In order to ensure future compliance the project director will instruct the supervisory staff that in the event of a patient death they are to complete an incident report immedicately and submit it to the project director. |