INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use the narcotic agents methadone and buprenorphine in the treatment of narcotic addiction. This inspection was conducted on May 20, 21, and 22, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Coatesville Treatment Center 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 June 20, 2008.
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Plan of Correction
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715.8(1)(vi) LICENSURE Psychosocial Staffing
A narcotic treatment program shall comply with the following staffing ratios as established in Chapter 704 (relating to staffing requirements for drug and alcohol treatment activities):
(vi) Outpatients. The counseling caseload for one FTE counselor in an outpatient narcotic treatment program may not exceed 35 active patients.
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Observations
Based on a review of counselor caseloads and staff interview, the facility exceeded the counselor to patient ratio of one full-time equivalent (FTE) counselor for every 35 active patients. Specifically, Counselor "A" had a caseload of 31 while working a thirty two hour work week which is a 41/1 patient to counselor ratio.
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Plan of Correction
The counselor's caseload has been reduced to the appropriate ratio. Counselor "A" will have no more than 28 patients on her caseload at all times.The clinic director will ensure that this is implemented. The clinical supervisors and or clinic director will monitor the caseload for continued compliance. |
715.10(c) LICENSURE Pregnant patients
(c) Counseling records and other appropriate patients records shall reflect the nature of prenatal support provided by the narcotic treatment program.
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Observations
Based on a review of 23 patient records of which three records were reviewed for compliance with prenatal care, the facility failed to ensure that pregnant patient # 7's record contained documentation of available prenatal supports and the services provided by facility staff. Specifically, patient # 7 entered treatment when she was pregnant; her treatment plan did not initially address her pregnancy nor did the admission documentation provide specific information to assist the patient in her need for prenatal care.
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Plan of Correction
The clinical will document prenatal care and any referrals for prenatal care for pregnant patients upon admission. Pregnancy will be addressed on the problem list on all patients upon admission. The clinical supervisors will monitor for compliance in bimonthly 1 on 1 supervision. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records, the Certified Registered Nurse Practitioners (CRNP) conducted a dose review for patient # 14 and increased the methadone dose. Documentation indicated the order was signed by the CRNP on 1/21/08 and signed by the physician on 1/24/08; the dose increase was effective with the date of the order, 1/21/08.
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Plan of Correction
The clinic director met with the PA and the MD on 5/22/08 regarding dosage adjustments and documentation needed as well as time frame for signatures of orders. The PA will indicate dosage increases via verbal order after consultation with the MD only when the MD is not on site. When the MD is off site the medical progress note will state dosage increase via verbal order and consultation with the MD by the PA. The MD will sign all verbal orders within 24 hours. The MD will complete all medical orders when he is on site. A meeting with the MD will occur to review this policy on 7/7/08. The clinic director will review the medical orders in random charts on a bimonthly basis to ensure compliance with protocol. |
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 upon review of the policy and procedure manual and record review of 26 patient records of which 13 were reviewed for compliance with take-home privileges, the facility failed to rescind take-home privileges for patient # 2 who did not receive any psychotherapy between August, 2007 and February, 2008 a period of 7 months without counseling.
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Plan of Correction
To ensure that patients with take home privileges are meeting the 8 point criteria the clinical supervisors will review noncompliance issues with the counselors on a monthly basis. The counselor's flow sheets will be reviewed which document counseling hours. The clnical supervisors will review patients with noncompliance issues and they will be presented at the weekly staff meeting with the entire treatment team regarding action. This will be implemented by July 15, 2008. |
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 23 patient records, the facility failed to provide each patient with the minimal requirement of an average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment in 3 of 7 records reviewed for compliance with psychotherapy hours:
Patient # 1 received 0.0 hours of psychotherapy in February 2008, 2.5 hours in March 2008, and 1.0 hour in April 2008.
Patient # 2 received 0.0 hours of psychotherapy services in February 2008, 0 hours in March 2008, and 1.0 hour in April 2008.
Patient # 22 received no psychotherapy services between August 2007 and February 2008.
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Plan of Correction
Counseling noncompliance will be reviewed by the clinical supervisors on a monthly basis. They will track noncompliant patients on a spreadsheet and schedule meetings with the patients and their counselors regarding this issue. The clinic director will monitor sheets on a monthly basis and meet with patients as necessary to address counseling noncompliance and a plan to address with patients. All interventions will be documented in the charts. The clinical supervisors will ensure this plan is implemented. The plan will be implemented by July 15, 2008. |
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 a review of 23 patient records, the facility failed to provide documentation that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose for 1 of 3 patient records reviewed for compliance with patient transfer requirements, specifically patient #6.
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Plan of Correction
The transfer coordinator will maintain a spreadsheet and track transfers into CTC on a daily basis. He will document the admission date and notification of the transferring clinic on this sheet after the notification letter has been sent. The clinical supervisor will monitor tracking of transfer patients as well as notification of completed transfer. This spreadsheet has been implemented on 6/23/08. |
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
The facility failed to restrict the policy and procedure on patient termination to the reasons permitted by regulation. Specifically, based on a review of 23 patient records of which 8 records were reviewed for discharge content, the facility involuntarily discharged 2 patients, # 13 and 16 for failure to comply with a financial agreement to pay for treatment.
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Plan of Correction
Financial Responsibility Interventions:
1)Patients with nonpayment issues will be notified by the office manager.
2)If the patient has not paid their balance after 5 days they will be referred to their primary counselor who will further address why there is nonpayment.
3) During this initial meeting the counselor will ask the patients the following questions:
How did this happen/ what is going on?
Have you applied for medical assistance?
Is the patient eligible for county funding?
How can we correct this?
A treatment plan will be created to address the financial issues occurring.
If the patient is not compliant with the plan established they will be placed on a contract. If the patient is not compliant with the contract the primary counselor will meet with them to reassess their financial situation. When can the amount due be paid?
Does the contract need to be adjusted?
If the patient needs to apply for medical assistance the patient has to continue to pay until medical assistance is approved. Applying for MA will be added to the treatment plan and follow up will be conducted each week with the patient.
If the patient is unemployed the patient should actively seek employment and it will be added to the treatment plan. Referrals will be given to Career Link in Coatesville as well as newspapers to review for job postings. Patients will be asked if they are in need of assistance with resume writing and interviewing skills.
4)Patients will be asked if family assitance is an option. A family meeting will occur if necessary to address the problems occurring.
5)If at any time during this process the patient remotely indicates difficulty budgeting the primary counselor will offer to review their budget with them in a session. Follow up will be conducted to verify that the patient is following the budget that has been set up with their primary counselor.
The above interventions will be established on an individual basis and modified as necessary due to patient's specific financial situations. These interventions are to assist patients with an inability to pay for treatment due to financial constraints/hardships.
When patients refuse to pay for services at CTC:
The patient will meet with the primary counselor to discuss what is going on?
The counselor will review options for the plan of care with the patient, funding options.
If the patient is requesting a taper off of Methadone in an inpatient setting he/she will be assessed regarding eligibility for Chester County Funding for treatment coverage. If the patient is not eligible for county funding and the patient has no other funding options an administrative taper will begin.
The patient will be given appropriate referral information for alternative treatment options.
When all efforts to sustain patients in treatment have been utilized and there is noncompliance with payment and contracts that have been established, an administrative taper will begin. If the balance is paid in full the administrative taper will cease. The administrative taper can be stopped 1 time. If payment is missed administrative taper will resume a second time and will be irreversible in order to avoid dose instability by starting and stopping a taper on several occasions. Frequent changes in doses can greatly effect the recovery of the patients. This can cause greater risk for overdose due to increased use of illicit opiods due to experiencing withdrawal symptoms and cravings from dose fluctuation from a pattern of tapers.
A balance meeting is scheduled every Tuesday at 1:00 PM to ensure the processes are being followed and the patient is being offered assistance needed to sustain them in treatment. A list of patient balances is given to all staff. The meeting consists of the clinical supervisors, clinic director and office manager. All patients are reviewed on this list regarding financial issues and interventions that are utilized and that need to be utilized. Patient contracts are reviewed in this meeting and compliance/noncompliance issues are discussed as well as a follow up plan. At the end of the meeting the office manager will flag patients in the computer to see her prior to dosing the next day regarding payment. For the more serious payment/financial issues the clinical supervisor/clinic director will flag patients in the computer to see them the next day to address concerns. The clinical supervisor will address other financial issues that need to be addressed by the counselors for follow up the next day. Counselors will place flags in the computer to see patients prior to dosing regarding financial status/progress/lack of progress. Treatment plans are reviewed and signed on a weekly basis by the clinical supervisors including financial treatment plans. Financial responsibility issues are reviewed in 1 on 1 biweekly supervision.
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715.23(b)(2) LICENSURE Patient records
(b) Each patient file shall include the following information
(2) A complete drug and alcohol history.
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Observations
Based on a review of 23 patient records, the facility failed to develop patient drug and alcohol histories that included length, pattern and progression of drug and alcohol use in 4 of 5 patients reviewed for compliance with drug and alcohol history content, specifically patient records # 7, 8, 21 and 23.
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Plan of Correction
Drug and alcohol history writing will be addressed in a training by the clinical supervisor by July 15, 2008. This will review the specific information required on drug and alcohol histories including the length, pattern and progression of drug use. The clinical supervisors will monitor in 1 on 1 bimonthly supervision for compliance as well as during random chart reviews. |
715.23(d) 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.
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Observations
Of the 26 patient records reviewed, 13 records were reviewed for the content of the treatment plan. The treatment plans contained global and non-specific goals; the contents did not address patient specific needs and goals as identified in patients' personal histories and psychosocial evaluations in 12 records, specifically, patient records # 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, 21, and 22. Additionally, these records included the same treatment goal to address financial compliance with treatment; the financial responsibility goals were global and did not provide clarification nor was any reason provided to include this on the patients' treatment plans.
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Plan of Correction
A training on treatment plan writing will be conducted by the clinical supervisor by July 15, 2008 to address specific objectives and interventions for treatment plans which will include examples of treatment plans. This will be monitored on a weekly basis when treatment plans are signed by the clinical supervisors. When the clinical supervisors identify treatment plan that is out of compliance this will be addressed in 1 on 1 supervision. The counselor will have 48 to make corrections. When the corrections are made the counselor and clinical supervisor will review the treatment plan to ensure it meets 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
Of the 26 patient records, 13 patient records were reviewed for treatment plan content. Twelve patient records, specifically # 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, 21, 22 and 23 contained vague, non-specific steps to reach their goals and the time frames were generalized rather than realistically specific to the action step.
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Plan of Correction
A training on treatment plan writing will be conducted by the clinical supervisor by July 15, 2008 to address writing specific objectives and interventions for treatment plans which will include examples of treatment plans. This will be monitored on a weekly basis when treatment plan are signed by the clinical supervisors. When the clinical supervisors identify a treatment plan that is out of compliance this will be addressed in 1 on 1 supervision. The counselor will have 48 hours to make corrections. When the corrections are made the counselor and clincial supervisor will review the treatment plan to ensure it meets compliance. |
715.23(d)(2) 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.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Of the 23 patient records, 13 records were reviewed for the content of the treatment plan update. The facility failed to document the progress or lack of progress in achieving the goals from the prior treatment plan in 9 of 13 patient records, specifically, patients # 3, 6, 8, 9, 10, 11, 12, 21, and 22.
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Plan of Correction
A training on treatment plan updates will be conducted by the clinical supervisor by July 15, 2008 to address progress completed as well as lack of progress. Examples of treatment plan updates will also be utilized. This will be monitored on a weekly basis when treatment plans are signed by the clinical supervisors. When the clinical supervisors identify a treatment plan is out of compliance this will be addressed in 1 on 1 supervision. The counselor will have 48 hours to make corrections. When the corrections are made the counselor and clinical supervisor will review the treatment plan to ensure it meets compliance. |
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 review of administrative documentation provided during the inspection and staff interviews, the facility failed to submit documentation of unusual incidents to the Department as required; specifically, the facility failed to notify the Department of the hospital treatment sought for patients # 21, 22, and 23.
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Plan of Correction
The clinic director will submit incident reports for all incidents involving hospital treatment of patients to the Department of Health. |