INITIAL COMMENTS
|
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 December 6-8, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Habit OPCO, Inc. 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.
|
Plan of Correction
|
715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
|
Observations
Based on a review of patient records, the narcotic treatment program failed to document what materials were sent to the receiving narcotic treatment program in one of one patient records.
The findings include:
Fifteen patient records were reviewed on December 6-8, 2011. Two records required documentation of the materials sent to the receiving provider of the transfer. In patient record # 11 there was no documentation of the materials being sent to the receiving narcotic treatment program.
Patient # 11 was admitted April 25, 2011 and discharged as a transfer to another narcotic treatment program August 3, 2011. A consent to release the required information was signed by the patient, but there was no documentation of what information was sent to the receiving facility.
|
Plan of Correction
The Program Director met with the staff on December 20, 2011 and reviewed the regulation and procedure. This included reviewing the use of the SMART software which provides for the required documentation in the Consent form.
Beginning on December 21, 2011 and for six months afterward, the Program Director will review all external transfers on a weekly basis to ensure that the procedure is being followed and that the documentation is correctly recorded. |
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.
|
Observations
Based on the review of patient records and administrative documentation, the narcotic treatment program failed to prepare a treatment plan that outlines realistic short and long-term treatment goals in five of five patient records.
The findings include:
Fifteen patient records were reviewed December 6-8, 2011. Treatment plans with realistic short and long-term treatment goals were required in five patient records. The policy and procedure manual, reviewed December 6, 2011, stated the comprehensive treatment plan would be completed within 30 days of admission.
Patient # 2 was admitted May 17, 2011. The comprehensive treatment plan was completed July 18, 2011, more than 30 days after admission.
Patient # 5 was re-admitted May 26, 2011, after being discharged as having completed treatment on May 17, 2011. A preliminary treatment plan was completed May 27, 2011, meant to cover the first 30 days of treatment. A treatment plan "update" of the patient's prior admission treatment plan was documented August 11, 2011 and was a repetition of the treatment plan of the previous admission. A new comprehensive treatment plan was not completed at the time of the inspection.
Patient # 6 was admitted June 28, 2011. A preliminary treatment plan was completed May 27, 2011, meant to cover the first 30 days of treatment. The comprehensive treatment plan was completed July 18, 2011, more than 30 days after admission.
Patient # 7 was admitted October 20, 2011. A preliminary treatment plan, meant to cover the first 30 days of treatment, was not completed at the time of the inspection. The comprehensive treatment plan was not completed at the time of the inspection.
Patient # 8 was admitted October 17, 2011. A preliminary treatment plan was completed October 14, 2011, meant to cover the first 30 days of treatment. The comprehensive treatment plan was to have been completed by November 13, 2011. The comprehensive treatment plan was not completed at the time of the inspection.
|
Plan of Correction
The Program Director met with the clinical staff on December 20, 2011 to review the deficiency and discuss the procedure to be implemented as of December 21, 2011. Each counselor has been instructed to come to weekly individual supervision with a list of treatment plans due, including Initial treatment plans and updates. The Program Director has developed a form to track which treatment plans are due and to follow up to make sure they are completed prior to the due date. The Program Director will maintain this list weekly for six months to ensure 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).
|
Observations
Based on a review of patient records, the facility failed to document the progress or lack of progress in achieving the goal statements from the prior treatment plan in three of four patient records.
The findings include:
Fifteen patient records were reviewed December 6-8, 2011. Four patient records were reviewed for treatment plan update documentation.
Patient # 1 was admitted May 26, 2011. A treatment plan was completed August 11, 2011. There was a treatment plan update in the patient's record dated for November 2011.
Patient # 2 was admitted June 28, 2011. A comprehensive treatment plan was completed August 16, 2011. There was a treatment plan update in the patient's record dated November 21, 2011 and there was no progress review of the patient's stated goals and objectives of the comprehensive treatment plan.
Patient # 12 was admitted March 17, 2009. Treatment plan updates are to be completed at least every 60 days. The patient was discharged August 9, 2011. A treatment plan update was completed August 2, 2011, more than 60 days after the last update, which was dated May 4, 2011.
|
Plan of Correction
The Program Director met with the clinical staff on December 20, 2011 to review the deficiency and the relevant policy. The SMART software was updated on December 12, 2011 to include the required documentation of progress or lack of progress. This will prevent counselors from being able to complete the update without including the information required. Since the Program Director has the responsibility for approving all treatment plans, no treatment plans will be approved without the required documentation. |