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, in the treatment of narcotic addiction. This inspection was conducted on October 29-31, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Habit OPCO, Inc. - Pottstown 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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715.8(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.
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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:
Administrative documentation that included counselor caseloads was reviewed and discussed with facility staff on October 29, 2013. The administrative staff acknowledged that they required another counselor, and in fact had recently hired a new counselor that would be starting in the near future.
Staff # 4 had a caseload of 39 to 1 according to administrative documentation reviewed on October 29, 2013.
Staff # 5 had a caseload of 37 to 1 according to administrative documentation reviewed on October 29, 2013.
Staff # 7 had a caseload of 38 to 1 according to administrative documentation reviewed on October 29, 2013.
Staff # 8 had a caseload of 36 to 1 according to administrative documentation reviewed on October 29, 2013.
Staff # 9 had a caseload of 37 to 1 according to administrative documentation reviewed on October 29, 2013.
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Plan of Correction
Currently this facility is fully staffed with 7 counselors to meet our census capacity of 245. Admissions were suspended to prevent further compliance issues. Proactive measures will be taken in the form of interviewing for potential employees to help protect against ratio issues due to staffing changes in the future. |
715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
Based on a review of patient records, the facility failed to maintain the confidentiality of patient information in two of eight patient records reviewed.
The findings include:
Sixteen patient records were reviewed October 29-31, 2013. Eight patient records were reviewed specifically for confidentiality compliance.
Patient # 13 was transferred to another narcotic treatment facility April 1, 2013. Information was released to the receiving facility without benefit of a signed written consent to release information.
Patient # 16 was admitted to the facility June 3, 2013. The patient was AWOL and it was learned the patient was in a behavioral hospital from July 26, 2013, who contacted the facility for information. Information was released without benefit of a signed consent to release information.
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Plan of Correction
Confidentiality will be reviewed and documented in the form of staff training for the upcoming calendar year. All staff will be required to review release forms on a quarterly basis for on-going changes. Staff will ensure proper consent forms are in place before releasing any information to any outside parties. |
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 the review of patient records, the facility failed to transfer the required patient files in three of three patient records reviewed.
The findings include:
Sixteen patient records were reviewed October 29-31, 2013. Three patient records required that the facility transfer specific patient files to the receiving narcotic treatment program as part of the transfer process. Three patient records did not transfer the specified files.
Patient # 11 was discharged as a transfer to another narcotic treatment facility October 16, 2013. The facility did not include medical summaries as required. In addition, the consent to release signed by the patient was restricted to 4 PA Code 255.5.
Patient # 12 was discharged as a transfer to another narcotic treatment facility September 16, 2013. There was no documentation the required patient files were transferred to the receiving facility or the written consent of the patient.
Patient # 13 was discharged as a transfer to another narcotic treatment facility October 16, 2013. The facility did not include medical summaries as required. In addition, there was no consent to release signed by the patient for the release of any information.
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Plan of Correction
Staff will be required to send all pertinent treatment information to the transferring clinic, inclusive of medical summaries, as outlined in Policy # 4.A.4.m. Consent forms to release said information will be obtained prior to discharge to ensure compliance with disclosure guidelines. |
715.23(b)(22) LICENSURE Patient records
(b) Each patient file shall include the following information:
(22) Aftercare plan, if applicable.
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Observations
Based on the review of patient records, the facility failed to complete an aftercare plan as required in two of two patient records.
The findings include:
Sixteen patient records were reviewed October 29-31, 2013. Two patients were discharged as having completed treatment.
Patient # 9 was discharged as completing treatment October 2, 2013. There was no documentation of an aftercare plan or that the patient refused an aftercare plan.
Patient # 10 was discharged as completing treatment April 29, 2013. There was no documentation of an aftercare plan or that the patient refused an aftercare plan.
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Plan of Correction
All patients who are in the process of completing MMTP will be offered aftercare services by their PC. Staff will document the decision of the patient to either participate in aftercare services or their refusal of such. Should the patient wish to continue counseling services elsewhere, a referral will be made to an appropriate community agency and documented accordingly. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on the review of patient records, the facility failed to complete annual evaluations in accordance with the regulations in five of seven patient records reviewed.
The findings included:
Sixteen patient records were reviewed October 29-31, 2013. Seven patient records required documentation of an annual clinical review.
Patient # 3 was admitted May 16, 2011. The second annual evaluation was due by May 16, 2013. The annual evaluation was not completed until June 28, 2013.
Patient # 5 was admitted September 8, 2009. There was no annual evaluation dated September 24, 2013 as listed in the record of services found in the patient record.
Patient # 7 was admitted May 16, 2012. The annual evaluation was due by May 16, 2013. The annual evaluation was not completed until June 28, 2013.
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Plan of Correction
Each patient will be assessed individually on an annual basis to determine the appropriateness of continued treatment. Primary Counselors will be required to complete this assessment by the close of the evaluation period for each patient and submit for review/signature of the Clinical Director and the Medical Director. On-going review of upcoming services due will be integrated into supervision of the counselors by the Clinical Director. |