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 9, 10 and 12, 2009, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Jf Kennedy Community MH/MR 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 December 18, 2009.
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Plan of Correction
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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 and an interview with administrative staff, the facility failed to demonstrate provision of at least one hour of physician services onsite per week for every ten patients enrolled.
The findings include:
The methadone monitoring questionnaire was reviewed with the facility director on November 9, 2009. The medical director was listed as providing 5 hours of physician time onsite per week. The medical director is a full time employee for the entire agency and his hours were not separated out to show when he was at this specific facility.
The questionnaire also listed 3 narcotic treatment physicians. One is temporary and the questionnaire listed him as providing 8 hours onsite per week. This physician's time sheets showed 7 hours per week onsite.
Another listed physician is the agency psychiatrist who provides 3 hours of onsite services per week. These hours were documented on the time sheets reviewed.
The third narcotic treatment physician was listed on the questionnaire as providing 8 hours of onsite patient services per week. He is also a physician for the entire agency and his his time sheets did not separate out the hours devoted to the narcotic treatment facility.
Based on the information provided, the facility had 10 hours of weekly physician services documented and the census had not dropped below 180 patients during the past year.
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Plan of Correction
Effective December 1, 2009 all physician hours are documented on a weekly calendar. This calendar reflects the name of the doctor, date and hours worked at the Methadone Clinic. The Clinic Director is responsible for maintaining our doctor's work calendar. |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on the review of patient records, the narcotic treatment program failed to document psychosocial evaluations in three of ten patient records.
The findings include:
Thirteen patient records were reviewed on November 9-10, 2009. Psychosocial evaluations were reviewed in ten patient records.
In patient records 4, 5 and 8 the psychosocial evaluations did not include an evaluation of the patient problems/needs, assets/strengths, support systems, coping mechanism, factors that may inhibit treatment. Instead, there was repetition of the historical data collected and patient reported information.
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Plan of Correction
The Division Director will conduct four (4) staff tranings by 3/22/09 to improve their skill at documenting psycho-social evaluations. Training will include case illustrations and practice scenarios. The Clinic Director will be responsible for monitoring each completed evaluation for compliance. |
715.23(d)(2) 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.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Based on a review of patient records, the facility failed to document the progress or lack of progress in achieving the goal statements from the prior treatment plan in three of six patient records reviewed.
The findings include:
Thirteen patient records were reviewed November 9-10, 2009. Six patient records required treatment plan update documentation.
Patient records # 1, 4 and 5 did not document patient progress towards meeting their respective goals. The information documented in the updates was not specific to the patient's progress with their treatment plan. Goals were dropped without documentation of the reason. Goal status could not be identified in the treatment plan updates.
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Plan of Correction
The Division Director will conduct four (4) staff trainings by 3/22/09 to improve their documentation of progress or lack of progress in client goal achievement. The Clinic Director will be responsible for monitoring treatment plans to ensure compliance. |