INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use narcotic agents, specifically methadone and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on January 6-8, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northeast Treatment Centers-Net Steps 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 February 7, 2009.
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Plan of Correction
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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 facility failed to ensure the annual physical exams were done in a timely manner in three of five patient records.
The findings include:
Sixteen patient records were reviewed on January 7 and 8, 2009. Annual physical examinations were required in five patient records. Patient # 5 was due to have an annual physical examination by October 3, 2008, but did not have a physical examination until November 18, 2008. Patient # 11 was due to have an annual examination in May 2008, but received an examination December 18, 2008. Patient # 18 was due to receive an annual examination in August 2008, but instead, was administered an annual physical examination December 19, 2008.
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Plan of Correction
A list of all annual physicals due will be distributed to the physicians at the beginning of each month. A database has been created in order for us to enter each physical as it is completed, update the lists daily and monitor the flow and timeliness of completion. Updates will be given to the physicians and other staff daily. The QA/PI director will train Program Director, Intake Coordinator, Supervisors, Nurses, schedulers and Physicians on this procedure by 3-1-09.
Staff Responsible: The PI/QA Director and the PI Assistant have created the database, will distribute results weekly and will directly/regularly follow up with Physicians to insure compliance. This procedure and its outcomes will be reported to Administrtaion in the montthly QA/PI report from 3/09 and ongoing |
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 facility failed to document psychosocial evaluations in two of two patient records.
The findings include:
Sixteen patient records were reviewed on January 7-8, 2009. Psychosocial evaluations were required in two patient records. The facility failed to provide an evaluative assessment of the patient history obtained that included the counselor's clinical analysis of the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, patient's attitude toward treatment and overall impressions. Instead, the psychosocial evaluations of the patient consisted primarily of the repetition of the history and statements reported by the patient in patient records # 15 and 17.
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Plan of Correction
The Intake Dept. is in the process of restructuring and upgrading the intake staff to include a "seasaoned" Intake Assessor. In addition , all current staff will be trained on this standard by the PI/QA Director. The intake Coordinator and PI/QA Director will monitor for compliance. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on the review of patient records, the facility failed to ensure the annual evaluation was signed and dated by the medical director in three of four patient records.
The findings include
Sixteen patient records were reviewed on January 7-8, 2009. Annual evaluations were required in four records. The facility did not have the medical director sign and date the annual clinical evaluation in patient records # 3, 16 and 18.
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Plan of Correction
The QA/PI Director will conduct a re-training of all applicable staff on this standard by 3-1-09. In addition the PI/QA director will monitor compliance into our ongoing QA process, identify compliance or lack thereof, address non-compliance and report finding via the monthly QA/PI.
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