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 October 22 through 23, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare York Pharmacotherapy Services 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 November, 25, 2008.
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Plan of Correction
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715.6(a)(2) LICENSURE Physician staffing
(a) A narcotic treatment program shall designate a medical director to assume responsibility for administering all medical services performed by the narcotic treatment program.
(2) When a narcotic treatment program is unable to hire a medical director who meets the qualifications in paragraph (1), the narcotic treatment program may hire an interim medical director. The narcotic treatment program shall develop and submit to the Department for approval a training plan for the interim medical director, addressing the measures to be taken for the interim medical director to achieve minimal competencies and proficiencies until the interim medical director meets qualifications identified in paragraph (1)(i), (ii) or (iii). The interim medical director shall meet the qualifications within 36 months of being hired.
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Observations
Based on a review of the Interim Medical Director's personnel record on October 22, 2008, the narcotic treatment program failed to submit to the Department for approval a training plan for the interim medical director.
Findings:
No documentation was made available during the methadone monitoring indicating the Department approved a training plan, developed by the Narcotic Treatment Program, for the Interim Medical Director.
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Plan of Correction
The training plan for the Medical Director was submitted to the state for approval on 10/23/08. When written approval of the plan has been recieved, documentation of the approval will be kept on site. |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on a review of six patient records on October 23, 2008, the narcotic treatment program failed to document psychosocial evaluations in two of two records, as required.
Findings:
In patient records #2 and 3, the psychosocial evaluation contained patient reported comments rather than the clinician's evaluation of the the patient, as required.
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Plan of Correction
Deficiencies in charts 2 and 3 were discussed with individual counselors on 10/24/08. All clinicians reviewed the assessment/evaluation requirements for the psychosocial evaluations on 10/28/08. All clinicians are to start using assessment rather than client reported information in the psychosocial evaluations as of 10/28/08. The content of psychosocial evaluations will be reviewed for compliance in this area in 1X weekly peer review and 1X monthly review of charts by the director. |