INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use a narcotic agents, specifically methadone, in the provision of outpatient maintenance treatment for opioid dependence. This inspection was conducted on January 11-13, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Foundations Medical Services, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were determined 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 a review of the Narcotic Treatment Program Monitoring Questionnaire completed by the facility on January 11, 2012, and an interview with the facility director, the facility failed to ensure that staff caseloads remained at or under 35/1.
The findings include:
On January 13, 2012, the counselor caseloads on the Narcotic Treatment Program Monitoring Questionnaire completed by the facility were reviewed. Based on the formula for the reduced caseload variance, Employee #2 has a caseload of 38/1. The other four counselors have caseloads under 35 / 1.
The findings were reviewed with the facility director and were not disputed.
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Plan of Correction
On June 9, 2011, the facility recieved approval for a caseload exception request from the Depratment. The exception stated the a counselor was permitted to carry a caseload up to 50 with specific stipulations. The program director operated the facility under general understanding of these stipulations as discussed with the specialist during the audit. During the exit, the specialist provided the Program Director and Director of NTP the formula used for calculating a reduced caseload. Effective January 13, 2012, the facility will implement the caseload exception as necessary and determine each counselor caseload size through the use of the formula provided. |
715.22(a) LICENSURE Patient grievance procedures
(a) A narcotic treatment program shall develop and utilize a patient grievance procedure.
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Observations
Based on a review of the grievances filed in 2011, the facility failed to utilize the patient grievance procedure.
The findings include:
On January 11, 2012, the patient grievance procedure and the patient grievances filed during the 2011 year were reviewed. There were no documented responses to grievances filed on 6-28-11, 6-30-11, 7-12-11, 7-25-11, 7-28-11, and 9-14-11. Other grievances filed on 7-10-11, 8-24-11, 8-30-11, and 10-5-11 did not include documentation consistent with facility procedure.
Facility procedure states that the Program Director will schedule a meeting with a multi-representative group of staff members, and will be responsible for documenting the process on a grievance worksheet / grievance report form. The worksheet will include a summary outlining the discussion and a decision on how to resolve the issue presented. A copy of the grievance report form will be sealed in an envelope and given to the patient via the nurse. The patient will sign upon receipt of the form. This process will be completed within 72 hours of receipt of the grievance.
The findings were reviewed with the facility director and were not disputed.
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Plan of Correction
The Program Director will ensure that all steps of the grievance policy and procedure will be followed, thus ensuring feedback given to the client is clearly documented. As the Program
Director is part of the process, compliance will be monitored as each grievance is received and through random monthly chart audits. All staff will be retrained on the grievance policy by February 15, 2012 |