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 November 27-29, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Habit OPCO, Inc. - Allentown 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
|
715.6(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
|
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 seven of the seventeen weeks reviewed.
The findings include:
Physician time sheets for the months of July, August, September, October and the beginning of November 2012 were reviewed on November 29, 2012. Seven weeks demonstrated insufficient onsite physician hours.
During the week ending August 4, 2012, the patient census was 179. The facility was required to provide at least 17.9 physician hours. There were 16 physician hours documented.
During the week ending August 11, 2012, the patient census was 180. The facility was required to provide at least 18 physician hours. There were 16 physician hours documented.
During the week ending August 18, 2012, the patient census was 176. The facility was required to provide at least 17.6 physician hours. There were 17 physician hours documented.
During the week ending September 1, 2012, the patient census was 173. The facility was required to provide at least 17.3 physician hours. There were 16.5 physician hours documented.
During the week ending September 29, 2012, the patient census was 175. The facility was required to provide at least 17.5 physician hours. There were 11 physician hours documented.
During the week ending October 6, 2012, the patient census was 176. The facility was required to provide at least 17.6 physician hours. There were 11.5 physician hours documented.
During the week ending November 3, 2012, the patient census was 167. The facility was required to provide at least 16.7 physician hours. There were 11 physician hours documented.
|
Plan of Correction
The Program Director, Medical Director, and Director of PA Operations reviewed policy 715.6(d) and the findings on November 30, 2012.
The Medical Director will submit a monthly doctor's hours schedule to the Program Director for review. The Program and Medical Director will ensure to pay close attention to holiday's and vacation time. Adjustments will be made to the schedule by the Medical Director in accordance to current census. A weekly census report will be run to ensure we are in compliance with the required doctor-patient time ratio.
|
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.
|
Observations
Based on the review of administrative documentation and discussion with facility staff, the facility failed to maintain counselor caseloads to no more than 35 to 1.
The findings include:
On November 27-29, 2012 a review of the administrative documentation that included the Narcotic Treatment Program Monitoring Questionnaire and the list of the patients being offered services at the facility, including those who were suspended for various reasons, was completed.
The questionnaire was reviewed with the facility director who reported the total number of patients to be 151 active and 13 suspended. The facility director also reported caseloads for the four counselors as totaling 125 active patients. There was a full caseload that had no assigned counselor due to the recent release of a counselor. The 13 suspended patients were not being counted in the total census needing an assigned counselor.
At the time of the monitoring, the facility had 39 patients that were not assigned to a counselor's caseload.
|
Plan of Correction
The Program Director reviewed policy 715.8(1)(vi) and its findings in reference to maximum caseload for one FTE in an outpatient narcotic treatment program with the Director of PA Operations on November 30,2012.
The Program Director will ensure compliance of this regulation by running and reviewing a counselor caseload report prior to the assignment of any new admissions, paying close attention to suspended clients. This will allow viewing of actual client / counselor ratios insuring total compliance with governing regulation 715.8(1)(vi).
|
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
|
Observations
Based on the review of patient records, the facility failed to ensure at least monthly random urine drug screens for five of twenty patients reviewed.
The findings include:
Twenty six patient records were reviewed November 27-29, 2012. Twenty patient records were reviewed specifically for monthly urine drug screen results.
Patient # 1 was admitted August 12, 2009 and discharged October 10, 2012. There was no drug screening urinalysis for June 2012.
Patient # 7 was admitted January 24, 2012 and discharged June 20, 2012. There was no drug screening urinalysis for May 2012.
Patient # 8 was admitted November 16, 2011 and discharged May 4, 2012. There was no drug screening urinalysis for April 2012.
Patient # 22 was admitted July 15, 2011 and discharged September 21, 2012. There was no drug screening urinalysis for April 2012.
Patient # 26 was admitted July 18, 2012. There was no drug screening urinalysis for August 2012.
|
Plan of Correction
The Program Director, Lead Counselor, and Director of PA Operations reviewed policy 715.14(a) and its findings on November 30, 2012.
The Clinical Director, lead counselor and clinicians will monitor client ua's during supervision to ensure the system is flagging all clients for a urinalysis test within the month. Any clients who have not been flagged within the first three weeks of the month will receive a forced test within the last week. This will allow us to monitor all urinalysis tests and identify any delayed alerts for testing through the system.
Furthermore, a clinical staff meeting will be held on December 20, 2012 to review policy 715.16(c)(1)(i-iv) and process will be shared with staff and monitored through weekly individual supervision.
|
715.16(c)(1)(i-iv) LICENSURE Take-home privileges
(c) A narcotic treatment program shall require a patient to come to the narcotic treatment program for observation daily or at least 6 days a week for comprehensive maintenance treatment, unless a patient is permitted to receive take-home medication as follows:
(1) A narcotic treatment program may permit a patient to reduce attendance at the narcotic treatment program for observation to three times weekly and receive no more than a 2-day take-home supply of medication when, in the reasonable clinical judgment of the narcotic treatment physician, which is documented in the patient record:
(i) A patient demonstrates satisfactory adherence to narcotic treatment program rules for at least 3 months.
(ii) A patient demonstrates substantial progress in rehabilitation.
(iii) A patient demonstrates responsibility in handling narcotic drugs.
(iv) A patient demonstrates that rehabilitation progress would improve by decreasing the frequency of attendance for observation.
|
Observations
Based on a review of patient records, the facility failed to ensure all patients demonstrated satisfactory adherence to the narcotic treatment program rules for at least 3 months prior to granting reduced attendance in one of eight patient records reviewed.
The findings include:
Twenty six patient records were reviewed November 27-29, 2012. Patient # 10 was admitted September 9, 2011. The patient's drug screening urinalysis were positive for illicit's since his admission until his last positive for illicit drug screen dated August 9, 2012. The patient's first negative screen was dated September 21, 2012. The patient had a second negative urine drug screen October 2012. The patient was granted take home privileges November 7, 2012, less than three months after his last positive drug screen.
|
Plan of Correction
The Program Director, Medical Director, and Director of PA Operations reviewed policy 715.16(c)(1)(i-iv) and the findings on November 30, 2012.
The Program/ Clinical Director and the medical Director will review urinalysis results during our take-home committee meeting calculating the status of the client's progress from negative urines only, to ensure clients are not being granted a premature reduction in treatment time requirements. Any clients that do not meet the requirements stipulated by this regulation will not be granted a reduction in attendance requirements.
|
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
|
Observations
Based on the review of patient records, the facility failed to transfer the required patient files in one of one patient record.
The findings include:
Twenty six patient records were reviewed November 27-29, 2012. Four patient records required the facility transfer specific patient files to the receiving narcotic treatment program as part of the transfer process. Three patient records did not show documentation the facility transferred the specified files.
Patient # 17 was discharged as a transfer to another narcotic treatment facility October 24, 2012. There was no documentation of the required patient files being transferred to the receiving facility.
Patient # 18 was discharged as a transfer to another narcotic treatment facility August 13, 2012. There was no documentation the required patient files were transferred to the receiving facility.
Patient # 20 was discharged as a transfer to another narcotic treatment facility August 3, 2012. There was no documentation the required patient files were transferred to the receiving facility.
|
Plan of Correction
The Program Director, Lead Counselor, and Director of PA Operations reviewed policy 715.20(1) and its findings in reference to the transfer of required client records on November 30, 2012.
The Clinical Director and Lead Counselor will ensure compliance of this regulation by requiring transfer and/or referral paperwork to be approved prior to sending information. Clinicians will be required to list documents being sent on cover sheet and filed in patient charts for future reviews. Chart reviews on closed charts will pay close attention to the documented released information.
Furthermore, a clinical staff meeting will be held on December 20, 2012 to review policy 715.20(1) and process will be shared with staff and monitored through weekly individual supervision as well as Clinical Director and staff chart reviews.
|
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.
|
Observations
Based on a review of patient handbook and the policy and procedure manual, the facility failed to restrict their policy and procedure on involuntary terminations to those areas specified in the regulations.
The findings include:
A review of the patient handbook on November 13, 2012 revealed that patients were informed they could be terminated for reasons other that those specified by regulations. According to the handbook documentation, patients could be terminated for reasons such as loitering, illicit drug use, funding/insurance issues and nonpayment for treatment services.
A review of the policy manual on November 13, 2012 revealed patients could be terminated for suspicious behaviors, falsifying urine drug screens, loitering, repeated non-compliance of safe parking laws, repeated failure to comply with the no visitor rule, failure to pay, and an immediate discharge without provision for detoxification when a physician "reasonably" determines continuous treatment presents serious risk.
|
Plan of Correction
The Program Director reviewed policy 715.21(1)(i-iv) and its findings in reference to policies and procedures for involuntary patient discharge with the Director of PA Operations on November 30,2012.
The Director of PA Operations is working with Corporate Officials to rewrite policy and procedures for involuntary discharges to follow the Regulations outlined by the state of PA to ensure compliance. Policy will follow PA guidelines and no patient will receive an involuntary discharge for any reason other than those stipulated in the PA regulations. Upon completion the Program/Clinical Director will replace existing policies with new policy and procedure which will be in our policy and procedure manual for reference and future site visits.
Furthermore, a clinical staff meeting will be held on December 20, 2012 to review policy 715.21(1)(i-iv). Policy changes will be discussed with staff and will be monitored by the Program/Clinical Director as the designee for discharge decisions with required signature. Progress will be monitored through scheduled Clinical Director and staff chart reviews.
|
715.22(c) LICENSURE Patient grievance procedures
(c) Penalties may not be initiated prior to final resolution with the exception that penalties may be initiated against patients who have committed acts of physical violence or who have threatened to commit acts of physical violence in or around the narcotic treatment program premises.
|
Observations
Based on the review of patient records and administrative documentation, the facility initiated a penalty prior to final resolution after issuing a letter of intention to involuntarily terminating a patient in four of five patient records reviewed.
The findings include:
Twenty six patient records were reviewed November 27-29, 2012. Five patient records were reviewed as administrative, or involuntary, discharges. The policy reviewed for the involuntary intent to discharge stated the patient would have three business days to appeal.
Patient # 21 was involuntarily terminated for an incident on September 19, 2012. There was a documented letter addressed to the patient stating the patient had been discharged effective September 19, 2012. There was no documentation the patient had received an opportunity to appeal the involuntary termination.
Patient # 22 was involuntarily terminated for an incident on September 21, 2012. There was a documented letter addressed to the patient stating the patient had been discharged effective September 24, 2012. There was no documentation the patient had received an opportunity to appeal the involuntary termination.
Patient # 23 was involuntarily terminated for an incident on July 2, 2012. There was a documented letter addressed to the patient on July 5, 2012 stating the patient had been discharged. There was no documentation the patient had received an opportunity to appeal the involuntary termination.
Patient # 24 was given a notice of intent to involuntarily terminate on July 10, 2012. The notice stated the patient had three business days to appeal the decision. However, the 21 day detoxification was actually started the next day, on July 11, 2012. There was no documentation that the patient had refused to appeal the termination of services.
|
Plan of Correction
The Program Director reviewed policy 715.22(c) and its findings in reference to involuntary discharges being implemented without the patient's right to appeal within 3 business days, with the Director of PA Operations on November 30, 2012.
The Director of PA Operation and Corporate Officials are re-writing company policy to follow suit with PA regulations to ensure no patient receives an involuntary discharge without the 3 day business day opportunity to appeal the decision. Upon completion of the policy, the Program/Clinical Director will replace existing policies with new policy and procedure which will be in our policy and procedure manual for reference and future site visits.
Furthermore, a clinical staff meeting will be held on December 20, 2012 to review policy 715.22(c). Policy changes will be discussed with staff and will be monitored by the Program/Clinical Director as the designee for discharge decisions with required signature. All appeal letters will be charted in patient file as proof that the procedure was followed. Progress will be monitored through scheduled Clinical Director and staff chart reviews.
|