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 November 30 - December 1, 2016, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania 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:
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Plan of Correction
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Fourteen personnel records were reviewed on November 30 - December 1, 2016. The facility failed to document a complete individual training plan that included input from both the employee and the supervisor in personnel records # 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility failed to comply with regulation 704.11 (b)(1) requiring the facility to maintain licensure individual training plan. Program Director and Clinical Supervisor will meet with counselor's to discuss trainings they would be interested in attending, along with the required trainings assigned. These specialized trainings will be incorporated within their individualized training plan. Program Director and Clinical Supervisor will conduct monthly audits to ensure selected trainings are completed. |
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
An onsite licensing inspection was conducted on November 30 - December 1, 2016. Based on the review of administrative documentation, the facility failed to consistently provide narcotic treatment physician services, at least one hour per week onsite, for every ten clients. During the licensing process, weekly physician time sheets were reviewed for the time period of 6/26/16 - 9/24/16. Insufficient onsite physician hours were provided for five weeks out of the time period reviewed. During the week of July 3-9, 2016, the average patient census was 365. The facility was required to provide at least 36.5 physician hours onsite. There were 30 onsite physician hours documented, including hours provided by the certified registered nurse practitioner. During the week of July 10-16, 2016, the average patient census was 361.9. The facility was required to provide at least 36.19 physician hours onsite. There were 11.38 onsite physician hours documented, including hours provided by the certified registered nurse practitioner. During the week of August 14-20, 2016, the average patient census was 369. The facility was required to provide at least 36.9 physician hours onsite. There were 32 onsite physician hours documented, including hours provided by the certified registered nurse practitioner. During the week of September 4-10, 2016, the average patient census was 376.3. The facility was required to provide at least 37.63 physician hours onsite. There were 21 onsite physician hours documented. During the week of September 18-24, 2016, the average patient census was 376.6. The facility was required to provide at least 37.66 physician hours onsite. There were 11 onsite physician hours documented. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to comply with regulation 715.6 (d) requiring to maintain physician staffing. The organization will employee an additional Nurse Practitioner to ensure all services are provided each week to patients. Program Director and Medical Director will review census of the program and assess number of hours needed to ensure program compliancy. |
715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
Six client records were reviewed on November 30 - December 1, 2016. The facility failed to document the countersignature of the medical director or narcotic treatment physician on records pertaining to functions conducted by the certified registered nurse practitioner in client record # 2. Client # 2 was admitted into treatment on 5/17/16 and was still active in treatment. The client's record documented that a semi-annual dose review was conducted by the certified registered nurse practitioner on 11/11/16. This documentation did not include the countersignature of the medical director or narcotic treatment physician. In addition, weekly physician time sheets were reviewed for the time period of 6/26/16 - 9/24/16. The facility failed to document that the narcotic treatment physician(s) provided one-third of the required time for one week out of the time period reviewed. During the week of July 10-16, 2016, the average patient census was 361.9. The facility was required to provide at least 36.19 physician hours. One-third of the required narcotic treatment physician(s) hours was 11.94. The onsite physician hours documented for the narcotic treatment physician(s) was 3. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to comply with regulation 715.6 (e)requiring records to be countersigned by the Medical Director. The organization has implemented the SMART system to include a countersign function which prompts for a Medical Director signature on all documentation completed by a Nurse Practitioner to ensure compliancy with state regulations.
Program Director and Medical Director will ensure facility provides the required physician hours to service patient census. An assessment of the census will be conducted on a weekly basis and physician scheduled hours will be allocated to cover all patient needs and services in order to ensure program remains in compliancy.
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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
Six client records were reviewed on November 30 - December 1, 2016. As the referring narcotic treatment program, the facility failed to document the transfer of all required patient files in client record # 5. Client # 5 was admitted into treatment on 6/8/16 and was transferred to another narcotic treatment program on 7/7/16. The results of the client's Mantoux/RPR tests were documented as being forwarded to the receiving narcotic treatment program on 7/5/16 but there was not documentation that following items were: medical and psychosocial summaries, dosage level, and urinalysis reports or summary. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility failed to comply with regulation 715.20 (1) requiring the facility to maintain patient transfer records. Clinical staff will receive an In-Service training by Program Director and Clinical Supervisor regarding the proper procedure of documentation needed to transfer in/out patients that is required to complete the transfer process. Clinical Supervisor and Lead Counselor will conduct weekly chart audits to ensure Narcotic Treatment Program received required documentation within seven days of transfer conducted. |
715.22(b) LICENSURE Patient grievance procedures
(b) The procedure shall permit aggrieved patients a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director. If the grievance is filed against the narcotic treatment program director, the review of the case shall be conducted by either a multi-representative group of the narcotic treatment program or a subcommittee of the governing body instituted for the express purposes of grievance adjudication.
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Observations
Six client records were reviewed on November 30 - December 1, 2016. The facility failed to provide documentation indicating that a review of a client's appeal was conducted in client record # 4.Client # 4 was admitted into treatment on 10/23/13. The client was involuntarily terminated from treatment on 5/16/16 due to non-compliance with treatment recommendations. The client's record indicated that the client received a written notification of termination on 5/4/16. The client then submitted a written appeal letter to the facility on 5/5/16. The facility failed to document in the client's record that the narcotic treatment program director conducted a review of the client's appeal of involuntary termination. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility failed to comply with regulation 715.22 (b) requiring the facility to maintain proper patient grievance procedures. Program Director, Medical Director, Clinical Supervisor and Counselor will review all patient appeals, once a determination is decided upon, a meeting will be scheduled with the patient to review the determined outcome. The findings will be documented within the patients case history in order to ensure the program maintains compliancy of regulation. |