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 July 5, 2011 through July 7, 2011 methadone monitoring inspection. The follow-up inspection was conducted on November 7, 2011 by staff from the the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Pyramid Healthcare York Pharmacotherapy 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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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of administrative documentation, the facility failed to provide at least one hour of physician time a week, on site for, every ten patients for one of the seventeen weeks reviewed.
The findings include:
Physician time sheets for the months of July, August, September, and October were reviewed on November 7, 2011. Seventeen weeks were reviewed along with the average census for those weeks. One week provided insufficient onsite physician hours during the week of September 25, 2011 through October 1, 2011. The patient census was 159. The facility was required to provide at least 15.9 physician hours. there were 12.5 physician hours documented. The amount of physician hours documented did not meet the required hours.
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Plan of Correction
Physicians have been retrained on documenting procedures to record exact hours of service provided per day on their timesheet.
Program Director will monitor weekly compliance by reviewing physician schedules in advance correlating with current census of program. |
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, the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment in three of seven records.
The findings include:
Ten patient records were reviewed November 7, 2011. Seven patient records were reviewed for psychotherapy hours during the first two years of treatment. Patient records
# 4, 6, and 10 failed to have the average of 2.5 hours of psychotherapy per month during their first 2 years of treatment.
Patient # 4 was admitted July 13, 2011. The average therapy hours were reviewed for the months of August, September, and October of 2011. The patient averaged 1.16 hours of psychotherapy for the three months reviewed
Patient # 6 was admitted September 10, 2010. The average therapy hours were reviewed for the months of August, September and October of 2011. The patient averaged 1.33 hours of psychotherapy for the three months reviewed.
Patient # 10 was admitted August 22, 2011. The average therapy hours were reviewed for the months of September and October. The patient averaged 2 hours of psychotherapy for the two months reviewed.
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Plan of Correction
All counselors will attend training on counseling guidelines, requirements for treatment and appropriate documentation of clients' treatment status.
Counselors will be required to document all interactions with clients and document follow up.
All counselors will continue to complete individual tracking grids to record the frequency of service provided.
Program Director will review tracking grids twice monthly to ensure compliance.
Counselors and Program Director will conduct monthly random chart reviews.
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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 the review of patient records, the facility failed to complete all required laboratory tests as part of the admission process in two of three patient records reviewed.
The findings include:
Ten patient records were reviewed November 7, 2011. Three patient records were reviewed for completed laboratory tests as part of the admission process, specifically a tuberculosis Mantoux test (PPD).
Patient records # 4 and 10 had documentation of tuberculin Mantoux test having been administered; however, the facility failed to document the results of the test within seventy-two hours.
The Director of Narcotic Treatment Programs confirmed this finding.
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Plan of Correction
Medical Team and Program Director have reviewed policies and regulations regarding completing laboratory testing and appropriate documentation of results in clients' individual files.
Medical Team has revamped internal process, specifically regarding tuberculosis Mantoux test (PPD), to avoid failure of test result documentation within 72 hours.
Necessary reporting forms are readily available to every medical personnel for completion within the 72 hour required timeframe.
Reminders have also been added into the computer system to complete the process.
Random chart reviews will be conducted by the medical team and Program Director to ensure compliance.
Additional training for Medical Team will be provided by Pyramid Healthcare's Director of Nursing to ensure understanding of company medical procedures.
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