INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the October 8, 2009 methadone monitoring inspection. The follow-up inspection was conducted on August 4, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Coatesville Treatment Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on August 29, 2010.
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Plan of Correction
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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 urine drug screens for three of four patient records.
The findings include:
Six patient records were reviewed August 4, 2010. Four patient records were reviewed for compliance with at least monthly random urine drug screens.
Patient record # 1 was missing a urine drug screen for December 2009 and February 2010.
Patient record # 3 was missing a urine drug screen for July 2010.
Patient record # 4 was missing a urine drug screen for July 2010.
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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 unknown reasons and as a result the system is not sending alerts each month on a small number of random patients. CTC is scheduled to implement a new dispensing system the week of September 22, 2010 which should elevate the problem. Until the new dispensing system is implemented, 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 |
715.23(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 a review of patient records, the facility failed to prepare a treatment plan with short and long term treatment goals in two of three patient records.
The findings include:
Six patient records were reviewed August 4, 2010. Three records were reviewed for treatment plans. Patient records # 1 and 3 contained treatment plans with a financial goal of maintaining payments to facility despite any documentation that the patients were encountering financial difficulties and unable to meet their monetary obligation to the facility.
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Plan of Correction
Counselors will be trained on 9/29/10 during a scheduled clinical team meeting to all problems related to financial goals is documented clearly on the treatment plan as well as the progress note. Clinical supervisors will review patient treatment plans minimally on a biweekly basis to ensure compliance in this area.
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