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 April 20 through 21, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, PA Care LLC D/B/A/ Miners Medical, 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 May 18, 2011.
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Plan of Correction
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715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on the review of patient information, review of administrative documentation and discussions with the facility director and administrative staff, the facility failed to follow their policy and procedure to demonstrate the efforts made to verify patient identity prior to dosing photograph as well as follow the procedure to update patient photographs every three years..
The findings include:
Per regulation, a narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient's name and birth date. The narcotic treatment program shall update the photograph every three years.
The facility policy stated "at admission Pinnacle Treatment Centers, Inc. provides each patient with a clear unalterable photo identification which includes the patient's name, addresses and telephone number. All identification cards contain both an issuance and expiration date. ID cards must be presented daily to the medical staff for identity verification prior to the administration of any medications.
The medication dispensing room was observed April 21 at approximately 9:30 AM. Patients did not present their identification cards to the nursing staff for identification but rather the nursing staff verified identification through the photo identification on the computer. A review of the photo identification contained the issuance date but did not contain the expiration date as stated in facility policy.
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Plan of Correction
The facility did not adhere to its policy and procedure regarding patient identificationby not including the expiration date on the picture ID.
It is the responsibility of the facility to include the expiration date on the program issued ID card.
The Facility Director is responsible for contacting TOWER to request inclusion of the expiration date to be included on the ID card formatted on the computer system.In addition, all patients will be reissued facility ID cards with all required information by 5/30.2011.
The Facility Director is responsible for implimentation and ongoing monitoring for compliance. |
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 a review of patient records and a discussion with the facility director and administrative staff, the facility failed to document an average of 2.5 hours of psychotherapy per month during the patient's first two years, in four of six patient records, as required.
The findings include:
Eight patient records were reviewed on April 20-21, 2011. Six patient records were reviewed for the completion of an average of 2.5 psychotherapy hours per month. Per regulation, 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. The facility failed to document an average of 2.5 hours of psychotherapy per month in patient records #1, 2, 7, and 8.
Patient # 1 was admitted into treatment on December 15, 2010. The patient attended 2.5 hours of psychotherapy in January, 2.5 hours of psychotherapy in February and 1.5 hours of psychotherapy in March. Patient #2 attended an average of 2.16 hours of psychotherapy per month. In addition the patient record contained documention of only 30 minutes of individual psychotherapy for the month of February.
Patient #2 was admitted into treatment on November 23, 2010. The patient attended 1 hour of psychotherapy in January, 2 hours of psychotherapy in February and 15 minutes of psychotherapy in March. Patient # 2 attended an average of 1.05 hours of psychotherapy per month.
Patient #7 ws admitted on October 12, 2010. The patient attended 1.5 hours of psychotherapy in January, 1 hour of psychotherapy in February and 0 hours of psychotherapy in March. It was documented in the patient record that the patient was in jail as of 3/21/11. Patient #7 attended an average of .83 hours of psychotherapy per month.
Patient #8 was admitted on December 29, 2010. The patient self terminated treatment on January 25, 2011 and then was readmitted on February 24, 2011. The patient attended 0 psychotherapy sessions in January and 1 hour of psychotherapy in March. Patient #8 attended and average of .5 hours of psychotherapy per month.
This was discussed with the facility director and administrative staff at the exit interview and it was confirmed that it was not documented in the patients records that patients were receiving and average of 2.5 psychotherapy hours per month.
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Plan of Correction
The facility failed to document an average of 2.5 hours of counseling per month for patients during their first two years in treatment.
It is the responsibility of the facility to provide an average of 2.5 hours of therapy per month, including a minimum of 1 hour of individual counseling to all patients during their first two years of treatment.
The Facility Director is responsible to provide training to all counseling regarding this regulation. In addition, the Facility Director is responsible for ongoing compliance through regular record review. Individual supervision will be utilized to provide ongoing training as needed. |
715.23(d)(1) 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.
(1) The treatment plan shall identify the behavioral tasks a patient shall perform to complete each short-term goal.
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Observations
Based on a review of patient records, and a discussion with the facility director, the facility failed to provide written documentation of the proposed type of support service, in the individual treatment and rehabilitation plans, in five of five patient records.
The findings include:
Eight patient records were reviewed on April 20 and 21 2011. The individual treatment and rehabilitation plans were required to document proposed type of support services in five patient records. The facility did not document proposed type of support services in patient records # 1, 2, 3, 4, and 8.
Patient # 1 was admitted on December 12, 2010. The individual treatment and rehabilitation plan was completed on January 15, 2011. There was no documentation of support services in the treatment plan.
Patient # 2 was admitted on November 23, 2010. The individual treatment and rehabilitation plan was completed on December 23, 2010 . There was no documentation of support services in the treatment plan.
Patient # 3 was admitted on January 24, 2011. The individual treatment and rehabilitation plan was completed on February 24, 2011. There was no documentation of support services in the treatment plan.
Patient #4 was admitted on January 24, 2011. The individual treatment and rehabilitation plan was completed on February 22, 2011. there was no documentation of support services in the treatment plan.
Patient #8 was admitted on February 24, 2011. The individual treatment and rehabilitation plan was completed on march 24, 2011. There was no documentation of support services in the treatment plan.
In a discussion with the facility director and administrative staff at the exit interview it was confirmed that supportive services were not being documented on the comprehensive treatment plans. Although the documentation is on the initial treatment plans supportive services are not included in the comprehensive treatment plans.
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Plan of Correction
The facility did not provide written documentation of proposed support services in the individual treatment plan.
It is the responsibility of the facility document any and all referrals to support services in the treatment plan.
The Facility Director will provide an onsite training of utilizing and identifying supportive services in treatment planning by 5/30/11 to all counseling staff. The Facility Director and lead counselor will review all treatment plans to ensure compliance with this regulation.
The Facility Director will monitor for ongoing compliance through regular record review.
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