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 5-6, 2012 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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715.9(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
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Observations
Based on the review of patient records, the facility failed to contact the previous narcotic treatment facility for the patient's treatment history in one of one patient record reviewed.
The findings include:
Fourteen patient records were reviewed March 5-6, 2012. One patient record required contact with the prior narcotic treatment facility for the patient's previous treatment history.
Patient record # 12 contained documentation that the patient reported a previous narcotic treatment experience at another narcotic treatment program. At the time of the inspection, patient # 12 was incarcerated and pregnant. A review of the patient record ( record # 12) revealed that there was no documentation provided that specified the patient's previous narcotic treatment facility had been contacted for information.
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Plan of Correction
Counselors will obtain releases for all previous narcotic treatment programs based on patient reports to obtain documentation. Clinical Supervisors will review all biopsychosocials. If the biopsychosocial indicates that there is a previous narcotic treatment admission, the Clinical Supervisor will review the patient chart to ensure there is a release and that previous treatment documention from the other facility was received. |
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.
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Observations
Based on the review of patient records, the facility failed to ensure at least monthly random urinalysis in five of nine patient records.
The findings include:
Fourteen patient records were reviewed March 5-6, 2012. Nine records were reviewed for initial and at least monthly urine drug screens. In the review of these records, it was identified that five patients did not receive the required urinalysis on a monthly basis.
Patient # 5 did not have a urine drug screen for August 2011.
Patient # 6 did not have a urine drug screen for January 2012.
Patient # 8 did not have a urine drug screen for September 2011.
Patient # 9 did not have a urine drug screen for February 2012.
Patient # 11 did not have a urine drug screen for December 2011.
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Plan of Correction
By 5/4/2012, clinical and medical staff will be trained on the requirements for urine drug screens as well as the new procedure. By the 30th of every month, Counselors will review patient charts to ensure that all urine drug screens have been appropriately filed. Director of Nursing will review urine drug screen report in the Tower system (patient data storage) by the 15th of every month to ensure patients have been scheduled for a urine drug screen. Patients that have been incarcerated or inpatient, Director of Nursing will make a note on the urine drug screen section of the charts so that readers will know why a urine was not given. Director of Nursing will reschedule all urine drug screens for patients that no show on the day the screening was scheduled. |
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 four patient records.
The findings include:
Fourteen patient records were reviewed March 5-6, 2012. Five patient records were reviewed for psychotherapy hours during the first two years of treatment.
Patient # 6 was admitted January 13, 2011. There were no psychotherapy hours documented for January or February 2012.
Patient # 8 was admitted September 9, 2009. There was no documentation of therapy hours in the patient record between August 19, 2011 and December 21, 2011 to determine if the patient was being seen in recent months.
Patient # 13 was admitted November 10, 2011. There was one hour of psychotherapy in December 2011, January 2012 and February 2012.
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Plan of Correction
Staff have been trained on the counseling requirements. They understand that patients that have less than two years of treament must have at least 2.5 hours of counseling every month. Staff were informed to notify their Supervisors immediately regarding counseling non-compliance. Patients that have been non-compliant with counseling have been flagged to attend the Positive Changes Group that is facilitated weekly to ensure that patients are being met with.
By the 25th of every month, Clinical Supervisors will run a report from the Tower System that tracks all counseling hours per patient per month. Patients that are short on hours will be flagged to attend group or individual session by the 30th of every month, and as needed they will meet for counseling prior to being medicated. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on the review of patient records, the facility failed to complete the annual physical with a re-evaluation by the physician in six of eight patient record reviewed.
The findings include:
Fourteen patient records were reviewed March 5-6, 2012.
Patient # 2 was admitted June 14, 2006. There was no annual physical exam in the patient record at the time of the monitoring inspection.
Patient # 3 was admitted October 12, 2009. The annual physical exam was completed on October 25, 2011 by the Certified Physician Assistant (PAc), but did not include a re-evaluation by the physician.
Patient # 4 was admitted August 16, 2010. The annual physical exam was completed on October 6, 2011 by the Certified Physician Assistant (PAc), almost two months late.
Patient # 5 was admitted January 26, 2009. The annual physical exam was completed on February 22, 2011 by the Certified Physician Assistant (PAc), but did not include a re-evaluation by the physician. It was almost one month late.
Patient # 8 was admitted September 9, 2009. The annual physical exam was completed on August 18, 2011 by the Certified Physician Assistant (PAc), but did not include a re-evaluation by the physician.
Patient # 9 was admitted November 16, 2010. The annual physical exam was dated November 22, 2011, but it was not signed and dated.
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Plan of Correction
Director of Nursing will meet with Nursing Staff by 4/30/2012 to educate them on the reuirements and new procedure that will be followed for annual physicals. Director of Nursing will schedule all physical exams a month prior to the due date. Physician will complete re-evaluations a month prior to the due date. Physician will also review all physicals performed by Physician Assistant and document and sign off on each physicial. |