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 October 6-8, 2009 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 and a plan of correction is due on November 7, 2009.
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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 a review of administrative documentation, the narcotic treatment program failed to submit to the Department for approval a training plan for the interim medical director.
The findings include:
The policy and procedure manual and attachments were reviewed on October 6, 2009. Personnel records that included the medical director's were reviewed on October 7, 2009. A training plan was located in the personnel record, but no documentation was provided during the methadone monitoring indicating the Department approved the training plan, developed by the Narcotic Treatment Program, for the Interim Medical Director.
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Plan of Correction
The physician whose record was reviewed is no longer employed by Coatesville Treatment Center (CTC). The Clinic Director is responsible for submitting a training plan to the department for approval. A new Medical Director has been hired by CTC. He started on 12/8/09. A training plan was submitted for the new Medical Director and was approved by the department on 12/4/09. Documentation verifying this will be maintained in the Medical Director's file. The Clinic Director is responsible for ensuring that the training plan for the Medical Director is fulfilled within the mandated time limitations. The Clinic Director will meet with the Medical Director quarterly to discuss progress on fulfilling the plan. The Clinic Director is responsbile for maintaining copies of training certificates and other verifying documentation in the Medical Director's file. |
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
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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.
The findings include:
Physician and physician assistant (PAc) time sheets and and census reports for the months of May, June, July and August were reviewed on October 6, 2009. The facility is licensed to medicate 590 patients and the census did not go below 400 patients during the time period reviewed. There were insufficient onsite physician hours during May and June.
The insufficient physician hours were discussed with the regional director on October 8, 2009. There are no physician hours scheduled Fridays through Sundays.
During the week of June 8-14, 2009, the total physician time was documented as 24 hours .
During the week of July 6-12, 2009, the total physician time was documented as 33.5 hours
During the week of August 3-9, 2009, the total physician time was documented as 24 hours
During the week of September 28-October 4, 2009, the total physician time was documented as 0 hours. The physician was on vacation and no time sheets for the PAc was presented for the timeframe.
During the week of October 5-11, 2009 the PRN physician was scheduled to work for 4 hours in addition to the PAc schedule, less than the one third required.
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Plan of Correction
The Clinic Director is responsible to ensure that the program has suitable physician time each week to meet the state requirement. Clinic Director will use able resources from CTC's sister program in Lebanon, PA, when substitute physician coverage is needed to meet the weekly time requirement. |
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 a review of patient records, the facility failed to ensure urinalysis was completed as required for four of ten patient records.
The findings include:
Sixteen patient records were reviewed on October 6-8, 2009. Ten patient records were reviewed for completed urinalysis results. Four patient records were missing documentation of a completed urinalysis.
Patient record # 6 did not have documentation of a completed urinalysis in July 2009.
Patient record # 9 did not have documentation of a completed urinalysis in September 2009.
Patient record # 11 did not have documentation of a completed urinalysis in April 2009.
Patient record # 16 did not have documentation of a completed urinalysis in February 2009.
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Plan of Correction
CTC's dosing system is designed to alert nursing staff during a given month to complete a UDS on each patient on randomly chosen dates by the software system. The dosing system is malfunctioning for no unknown reason and as a result the system is not sending alerts each month on a small number of random patients. CRC Health Group is piloting new dosing systems. Once a corporate decision has been made, CTC will receive a new dosing system. The Director of Nursing is responsible for manually tracking urine screens to catch missed patients prior to the end of each month and for ensuring that UDS's are completed on all active patients every month. As a secondary measure, counselors will monitor their caseloads each month and communicate to the Director of Nursing if any of their patients have not had a UDS by the 25th of every month. |
715.20 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.
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Observations
Based on the review of patient records, a patient interview and an interview with a clinical supervisor, the facility failed to initiate a patient transfer within 7 days of the patient's request in one of one patient records.
The findings include:
On October 8, 2009, patient # 9 was interviewed regarding her treatment and her pregnancy care. Patient was admitted from the Delaware County Prison in June 2009. By patient report, she lives in another county. The patient reported she takes two trains daily to come to the clinic and has missed dosing due to the lack of transportation on certain days. She requested a transfer in writing on July 29, 2009, and this letter was placed in the patient's record. There was no documentation by the counselor of any communication with the requested facility when the record was reviewed on October 8, 2009. The patient gave permission for the facility to be contacted. In a telephone discussion with the director of the other facility, only the patient had contacted them for admission.
Coatesville Treatment Center's clinical supervisor completed the paperwork with the patient and faxed the information to the other facility. A follow up call to the facility verified the paperwork was received and an appointment made for the transfer intake to be completed.
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Plan of Correction
The counselor of the patient identified by the monitor in her observations has been counseled and provided a plan of correction to address the issues that propagated her failure to comply with the transfer policy and procedures. Clinical Supervisors will review patient transfer policies and procedures with counselors during an upcoming clinical team meeting to ensure that counselors are clear with the expectations and timelines when transferring patients. Counselors will inform their Clinical Supervisor within 24 hours when a patient makes a request for transfer. The Clinical Supervisor is responsible for providing supervisory oversight during the transfer of the patient to ensure that all appropriate steps are taken by the counselor within the required timelines. |
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 narcotic treatment program failed to document the results of annual reevaluations by the narcotic treatment physician as part of the annual physical exam in eight of nine patient records.
The findings include:
Sixteen patient records were reviewed on October 6-8, 2009. Annual reevaluations by the narcotic treatment physician in the annual physical exams were required in nine patient records. Seven of the nine annual physical exams were completed by the PAc. Patient # 10's exam and evaluation was not documented in the patient record. The narcotic treatment program failed to document the results of the annual reevaluation by the narcotic treatment physician in patient records # 2, 5, 6, 7, 8, 10, 14 and 16.
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Plan of Correction
The Director of Nursing (DON)is responsible for tracking and scheduling annual reevaluations for all active patients. The DON has developed and implemented a tracking system that ensures that patients who do not show for or do not complete their scheduled reevaluations are rescheduled and the reevaluation is completedin a timely manner. The new Medical Director will jointly complete all annual physical examinations with the Physician Extender. The DON is responsible for monitoring the tracking system for completeness and for ensuring that the results of the annual reevaluations are documented in the patient records. |
715.23(b)(11) LICENSURE Patient records
(b) Each patient file shall include the following information:
(11) Counselor notes regarding patient progress and status.
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Observations
Based on a review of patient records, the facility failed to consistently and regularly document the patient's progress and status in nine of eleven patient records.
The findings include:
Sixteen patient records were reviewed on October 6-8, 2009. Eleven patient records were reviewed for documentation of patient's progress and status in treatment.
Patient # 1 was admitted 10-28, 2008. Patient had an orientation group dated 12-19-08. There was no documentation to provide rationale for patient #1 not receiving program orientation until almost 2 months after admission.
Patient records # 5, 6 & 7 did not include an assessment of the data collected for the sessions documented.
Patient # 9 did not have a progress note documented since 8-21-09, though she attends the clinic daily to dose.
Patient # 11 was admitted 6-16-08. The first individual counseling note was dated 2-20-09. There were no notes describing any contact between 4-21-09 and 7-30-09.
In patient records # 12 & 14 the assessment sections of the DAP did not include an assessment.
Patient # 15 contained notes that were unable to be read, therefore unable to determine if the progress and status was documented.
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Plan of Correction
Patient records will be reviewed by peer counselors on a quarterly basis. Peer reviewers will provide counselors with written feedback pertaining to their findings, including whether or not the record reflected consistent and regular documentation of the patient's progress and status. Counselors, under the guideness and advisement of their Clinical Supervisor, will be responsible for making any and all appropriate corrective actions to bring their patient records into compliance. Clinical Supervisors will provide training to counselors during an upcoming clinical team meeting and ongoingly during individual supervisory sessions regarding progress note writing. |
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 the review of patient records and discussion with staff, the facility failed to prepare treatment plans with realistic treatment goals in six of six patient records reviewed.
The findings include:
Sixteen patient records were reviewed October 6-8, 2009. Six patient records were reviewed for treatment plan goals. Patient records # 1, 9, 10, 11, 12 and 13 had financial goals listed without financial problems identified. Staff interview revealed the goals were written as a preventive measure to ensure the patients maintained the medical coverage without any documentation elsewhere in the record that they were having financial problems. Patient record # 1 had a treatment plan with financial goals prior to his losing his job and insurance.
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Plan of Correction
Patient treatment plans will be reviewed by the clinical supervisors during biweekly individual supervision sessions with each counselor. Clinical supervisors will ensure that counselors are writing individualized treatment plan goals that are realistic and applicable for each patient. Counselor will be provided training in individualized treatment planning and treatment plan/goal writing quarterly through Clinical Team meetings lead by the clinical supervisors and/or when available, through documented external professional development opportunities. |