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 and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on March 5-7, 2013 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 4 PA Code and 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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715.19(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 four of six patient records.
The findings include:
Twenty five patient records were reviewed March 5-7, 2013. Six patient records were reviewed for psychotherapy hours during the first two years of treatment. The months of December 2012, January 2013 and February 2013 were reviewed for an average of at least 2.5 hours of psychotherapy per month.
Patient # 4 was admitted October 17, 2012. Patient # 4 received an average of 1.8 hours of psychotherapy over the three months reviewed.
Patient # 5 was admitted November 15, 2012. Patient # 5 received an average of 2 hours of psychotherapy over the three months reviewed.
Patient # 9 was admitted October 23, 2012. Patient # 9 received an average of .6 hours of psychotherapy over the three months reviewed.
Patient # 18 was admitted February 7, 2012. Patient # 18 received an average of 1.16 hours of psychotherapy over the three months reviewed.
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Plan of Correction
There will be three new Groups added that will be facilitated each week entitled Positive Changes, Mon., Wed,, and Fri. at 12:30p. Patients that have missed counseling and have other issues with non-compliance will have to attend these groups. Patients will me scheduled to medicate at 12:29p and then will be escorted back to the front lobby to attend group. Clinical Supervisor will ensure that the group is being facilitated and will have Counselors go over a list of patients that have issues with non-compliance during bi-weekly supervision. Patients that are non-compliant with counseling requirement will have to meet with primary counselor and Clinical Supervisor and will have to attend the Positive Changes groups until they have met all counseling requirements. Clinical Supervisors will be responsible for addressing issues with counseling requirements. There will be training on 4/1/2013 conducted by the Clinical Supervisors to go over the new procedure. There will also be a notice posted in the lobby for all patients to view regarding the new groups. |
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.
The findings include:
Administrative documentation that included unusual incident reports was reviewed March 5, 2013. Incidents with the potential for negative community reaction or concern were documented, but there was no documentation that the incidents were reported to the Department as required.
Two different incidents in which police were called because of patient behaviors that could have affected the community were not reported to the Department. One patient was under the influence of alcohol and was seen driving away from the facility and police were called. Another patient threatened suicide, refused to dose and the police were called as the patient left the facility.
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Plan of Correction
Clinic Director will be responsible for ensuring that all Unusual Incidents will be faxed within 48 hours to the Division of Drug and Alcohol Programs. The Unusual Incident reports will no longer be sent via email. All Unusual incidents will be directly submitted to Clinic Director. Clinic Director will monitor this process. Staff will be trained on what is considered an Unusual Incident on 4/3/2013. |