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, for the treatment of narcotic addiction. This inspection was conducted on November 14, 15 and 16, 2007 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 corrections are due on December 18, 2007.
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Plan of Correction
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715.6(a)(2) LICENSURE Physician staffing
(a) A narcotic treatment program shall designate a medical director to assume responsibility for administering all medical services performed by the narcotic treatment program.
(2) When a narcotic treatment program is unable to hire a medical director who meets the qualifications in paragraph (1), the narcotic treatment program may hire an interim medical director. The narcotic treatment program shall develop and submit to the Department for approval a training plan for the interim medical director, addressing the measures to be taken for the interim medical director to achieve minimal competencies and proficiencies until the interim medical director meets qualifications identified in paragraph (1)(i), (ii) or (iii). The interim medical director shall meet the qualifications within 36 months of being hired.
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Observations
Based on the review of the interim medical director's personnel file and staff interviews, the facility failed to submit a training plan that addressed the measures to be taken for the interim medical director to achieve minimal competencies and proficiencies.
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Plan of Correction
Training plan for the medical director was submitted by the CLinic Director to the DOH. |
715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on random patient record review, the facility failed to ensure the narcotic treatment physician documented a face to face determination of current dependency in two of five patient records reviewed, #2 and 22.
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Plan of Correction
The clinical supervisor will review the history and physical forms on all new admissions daily while completing new counselor assignments to assure face to face determination is documented by the physician. Beginning on 12/1/07 for 6 months. Followed by the Clinical supervisor ensuring ongoing compliance by conducting random chart audits monthly for three months following the 6 month timeframe completed by the clinic director to ascertain that the NTP physician documented a face to face determination of current dependency.
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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 random patient record review, the facility failed to ensure that the narcotic treatment physician consulted with the physician assistant, who had completed the physical examination. This was not conducted and documented prior to determining the patient's initial dose and medication schedule for two of five patient records reviewed, #2 and 22.
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Plan of Correction
The clinical supervisor will review all history and physicals on the admission charts on the morning of the admission to ensure that consultation with the physician extender occurred prior to the admission of the patient into the treatment center. The clinic director will meet with the medical director and physician extender by 1/4/08 to review the protocol for consultation prior to patient's initial dose and medication schedule. |
715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
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Observations
Based on random patient record review, the facility failed to ensure the narcotic treatment physician documented in the patient record the rationale for permitting take-home medication, instead the facility allowed other staff members to make this determination with the physician then "agreeing" with them.
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Plan of Correction
Beginning on 12/12/07 the physician will document on case consultations the disposition of each case. The documentation will state whether the take home privileges were approved, removed or denied as well as the rationale for the decision made by the doctor. All case consultations will be reviewed by the clinical supervisor or clinic director during the weekly staff meetings. To ensure ongoing compliance this will become part of the policy for Coatesville Treatment Center from 12/12/07 on. |
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 random patient record review, the facility failed to provide sufficient hours of psychotherapy for five of five patient records reviewed, #2, 11, 16, 18 and 20. In addition, the treatment plan focus for therapy hours did not reflect the needs of the patient, but rather the minimum required by regulation.
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Plan of Correction
Starting January 2008,the clinic will increase counseling hours for new patients for the first 90 days. Counseling hours will be increased based on some of the following individualized patient needs including, but not limited to, the following factors: length in treatment, unstable living arrangements, lack of support, mental health/medical issues, financial issues and current use. All attempts to increase counseling will be documented by the primary counselor in a progress note. The treatment plans and the DAP notes will be reviewed by the clinical supervisors on a weekly/bimonthly basis during one on one supervision to ensure counselors are appropriately documenting and identifing the need for additional counseling and the rationale for such increases. Rationale for increased counseling will be addressed in a staff training to be conducted by the clinical supervisors by January 14, 2008. |
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.
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Observations
Based on random patient record review, the facility failed to demonstrate the transfer of the required patient files for four of four patient records reviewed, # 10, 12, 14 and 26.
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Plan of Correction
The transfer protocol will be reviewed in a training conducted by the clinical supervisors by January 14,2008. The clinical supervisors will be notified of all patient transfers to other facilities. The clinical supervisors will review all information noted on the transfer fax cover sheet as well as the release of information to ensure that proper documentation is being faxed. The clinical supervisors will also review the fax confirmation sheet to ensure that proper documentation was received at the transfer facility. The clinical supervisors will follow up with the appropriate counselor within 24 hours to confirm that transfer is complete and review transfer letter from the facility. This deficiency will be corrected by 1/15/08. |
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 random patient record review, the facility failed to document notification to the referring narcotic treatment program of the admission and date of initial dose of the patient in four of four patient records reviewed, # 18, 22, 28 and 30.
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Plan of Correction
Beginning on 12/10/07 The clinical supervisor will monitor admissions on a daily basis and will review the transfer letter, fax confirmation sheet. The clinical supervisor will consult with our transfer coordinator biweekly regarding possible transfers, paper work needed for transfers and monitor compliance that document notification to the referring narcotic treatment program of the admission and date of initial dose of the patient was completed. |
715.21 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.
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Observations
Based on random review of patient records, the facility failed to ensure all efforts had been initiated to retain the patient prior to the involuntary termination. Patient # 2, was admitted on June 11, 2007 and involuntarily terminated on July 6, 2007 for financial reasons. The patient was reinstated before the detoxification was completed and then involuntarily terminated again on September 7, 2007, again for financial reasons. While financial responsibility was placed on the treatment plan, it was standardized and did not provide the specifics necessary to meet the goals. The brevity of this time period does not allow for clinical interventions nor for the lack of financial responsibility to be treated as a clinical issue.
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Plan of Correction
Financial responsibility will be addressed on individualized comprehensive treatment plans. All interventions surrounding these issues will be documented in the patient chart. Clinical supervisors will address treatment plan writing as well as specific interventions and resources to be utilized for financial responsibility in a training to be held in January 2008. These will include the medical assistance process, county funding eligibility and process, agencies that assist in obtaining employment, interviewing skills, budgeting information.
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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
Based on random patient record review, the facility failed to restrict involuntary detoxification of patients to the reasons permitted by regulation. In eleven discharged patient records that were reviewed, two patients were involuntarily terminated and detoxed from methadone maintenance for non-payment, # 2 and 24. The issue of financial responsibility is a long term clinical issue that needs to be addressed on an individual therapeutic basis.
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Plan of Correction
Financial responsibility will be addressed on individualized comprehensive treatment plans for patients that have financial responsibility issues. All interventions surrounding these issues will be documented in the patient chart. Clinical supervisors will address financial responsibility and the interventions and resources to be utilized in a training to be held by January 14, 2008. These will include the medical assistance process, county funding eligibility and process, agencies that assist in obtaining employment, interviewing skills and budgeting information. The financial responsibilities of patients will be reviewed by the clinical supervisors on a bimonthly basis in one on one supervision to ensure that the appropriate interventions are being utilized.
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715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on random review of patient records, the facility failed to develop an evaluative assessment of the historical data obtained that included the counselor's clinical impressions. Instead, the psychosocial evaluations of the patient consisted primarily of the repetition of the history and statements reported by the patient in three of five patient records reviewed, #2, 14 and 16.
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Plan of Correction
A training will be conducted by January 14,2008 by the clinical supervisors for all clinic staff to address writing evaluative statements. Examples of psychosocial histories and interpretive summaries will be given to all counselors to assist. All psychosocial histories and interpretive summaries will be reviewed by clinical supervisors upon completion during one on one supervision. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on random patient record review, the facility failed to state the patient's specific reasons for entering the treatment program or the summation of the patient's treatment goal progress over the course of the overall treatment experience. The facility documented opiate dependence as the reason for treatment and a description of the reasons for discharge as the summation of treatment for eight of ten patient records reviewed, # 2, 4, 6, 10, 12, 14, 24 and 26.
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Plan of Correction
The reason for entering the treatment program will be documented in detail on all discharge summaries. This will be obtained from the patient via the intake/screening sheet prior to admission. A training will be conducted by January 14,2008 by the clinical supervisors for all clinical staff which will include examples to be given to all counselors to illustrate expectations of discharge summary documentation. The clinical supervisors will review all discharge summaries for compliance including the reason for entering the treatment program. |
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
Based on random patient record review and staff interviews, the facility failed to develop individualized treatment goals for the patients admitted to treatment, but rather established the same generalized treatment goals regarding financial responsibility for all patient records reviewed, whether financial problems were indicated or not.
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Plan of Correction
Individualized treatment plan goals will be developed for all patients. Treatment plan writing will be addressed in a training to be conducted by January 14,2008 by the clinical supervisors for all clinical staff. The training will provide resources to be given to clinical staff to assist in understanding and knowledge of the requirements. This will cover identifying problems in the psychosocial history. It will clarify how to write an individualized treatment plan with examples of problems and goals as well as specific interventions that can be utilized. All treatment plans are reviewed and signed by clinical supervisors on a weekly basis.
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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 the program's incident reports and staff interviews, the facility failed to file a report for all required unusual incidents. In reviewing the facility file on unusual incident reports, there were several incidents involving drug-related hospitalizations of patients and incidents for negative community reactions that had not been submitted to the Department for review as required.
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Plan of Correction
This was an over site of the clinic director. Unusual incident reports will be completed and submitted to the Department for review within 48 hours for drug related hospitalizations and incidents that may negatively affect the community in addition to and all other required reporting of additional unusual incidents by the clinic director and will be monitored by the safety coordinator during monthly safety meetings when all incident reports are reviewed.
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