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 and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on July 22 & 23, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Freedom Healthcare Services, Llc. was found not to be compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and a plan of correction is due on August 16, 2009.
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Plan of Correction
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715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
Based on a review of patient records and a staff interview, the facility failed to provide an appropriate dosage level for the patient in one of eight records.
The findings include:
Twelve patient records were reviewed July 22 and July 23, 2009. Eight records were required to have dosage orders. Patient # 8 had a current Suboxone dose ordered by the physician of "2 and a half tablets". A Suboxone tablet is not to be halved or scored. A staff interview concluded that staff were aware that medication orders were not to be issued with doses that required the tablet to be split.
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Plan of Correction
Freedom Healthcare's narcotic treatment physician has stopped writing prescriptions for patients in half tablets increments as of 8/1/09.
The Project Director will ensure ongoing compliance and will audit charts regularly. |
715.18(a)(3) LICENSURE Rehabilitative services
(a) A narcotic treatment program shall provide, either onsite or through referral agreements, a full range of rehabilitative services. Rehabilitative services shall include:
(3) Adult educational services.
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Observations
Based on a review of policy and procedures a staff interview, the facility to provide documentation of referral agreements for adult educational services.
The findings include:
Facility referral agreements were reviewed July 22 & 23, 2009. The facility failed to document a referral agreement for adult educational services. A staff interview revealed and concluded that the facility did pursue referral agreements for this service but had failed to secure a signed agreement for this rehabilitative service.
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Plan of Correction
Adult educational referral agreements were contacted initially via email as well as referral agreements were mailed on 8/11/09 to six different organizations. One of the organizations has agreed to sign the referral agreement. The Project Director will ensure that an educational referral is secured within the next 30 days. |
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 the review of patient records, the facility failed to provide documentation that patients received a minimum of 2.5 hours in 3 of 8 patient records.
The findings include:
Twelve patient records were reviewed July 22 & 23, 2009, eight were required to show documentation of an average of 2.5 psychotherapy hours per month. The facility failed to provide documentation that an average of 2.5 psychotherapy hours per month had been provided in three patient records.
Patient # 1 was admitted to treatment May 22, 2009; the patient has had no pychotherapy since 6/17/09.
Patient # 2 was admitted to treatment February 27, 2009; the patient had 2.25 hours of pychotherapy in April, 2009, 0 hours in May and 2.5 hours in June.
Patient # 8 was admitted to treatment in February 10, 2009; the patient received 2 hours of psychotherapy in April, 2009, 0 hours in May and 1.5 hours in June.
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Plan of Correction
Freedom Healthcare has recently begun using a computer system that contains all patient information. Patients are required to check in with the front desk as they enter the building. Freedom Healthcare will begin a new process of ensuring that the patients meet their counseling time. The primary counselors will place "holds" on all of the patients the day before that they may need to see the following day. When the patient checks in with the front desk, they will be informed as to whether they have a counseling appointment. All patients that have a counseling appointment will require seeing their counselor prior to their medical appointment. Before the patient checks in for their medical appointment, they must present a slip from their counselor verifying that they attended counseling. Freedom Healthcare will also inform patients by creating a newsletter to be completed by 8/21/09. Patients will be informed for the next two weeks of the new process and allow them time to schedule with their counselor. The new process will then begin by 9/7/09 and will be monitored/implemented by the Project Director. When the Project Director is not at the facility then this process will be monitored by the clinical supervisor. |
715.21 LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
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Observations
Based on a review of policy and procedures and patient records, facility documentation identified reasons for discharge that exceeded the guidelines for patient termination in a narcotic treatment facility.
The findings include:
Documentation reviewed on-site July 22 & 23, 2009 revealed that patients were provided a form to sign at admission that identified facility rules. One of the rules specified that a patient "may be discharged for missing or being late for a rescheduled appointment". Further, a review of the patient handbook specified that a patient could be discharged for breaking facility rules. Reasons given for potential discharge included failure to pay for services, failed session attendance, failure to provide a urine sample for drug-screen testing and loitering. These reasons for potential discharge exceed the guidelines for involuntary termination.
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Plan of Correction
All forms have been revised and edited as of 8/1/09. The form that stated "may be discharged for missing or being late for a rescheduled appointment" was edited and the sentence was taken out. The other form was revised to be compliant the State guidelines for termination. Also the patient handbook was changed to reflect the updated information. |
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 five of eight patient records.
The findings include:
Twelve patient records were reviewed on July 22 & 23, 2009. Psychosocial evaluations were required in eight patient records. The facility failed to document a psychosocial evaluation that included a clinical assessment of the patient's problems and needs, assets and strengths, support systems, coping mechanisms, factors that might inhibit treatment and clinical recommendations, in patient records #1, 5, 6, 7 and 8.
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Plan of Correction
Freedom Healthcare will begin training for the psychosocial evaluations as of 8/31/09. The clinical supervisor will review all psychosocials as they are completed and do individual training with each of the counselors. The clinical supervisor will focus on identifying patient's problems and needs, strentghs, suport systems/referrals, coping skills, factors that may inhibit treatment and clinical recommendations including prognosis. The clinical supervisor will report directly to the Project Director over the next 30 days to report progress. All training of the psycho-social evaluations will be completed by the clinical supervisor by 9/30/09. |
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 the review of patient records, the narcotic treatment program failed to document support services in treatment plans in four of six patient records.
The findings include:
Twelve patient records were reviewed on July 22 and 23, 2009. Treatment plans were required in six patient records. The narcotic treatment program did not document support services that were specific to the treatment plan goals in patient records # 2, 4, 6 and 8.
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Plan of Correction
The clinical supervisor has put together a binder of support services that all counselors will have access to. The binder is broken down by the type of service offered so that it will be easier for the clinical staff find. The clinical staff will then begin utilizing these services on their treatment plans as 8/31/09. The Project Director will make should that the clinical staff are utilizing the support services and will continue to monitor this progress. |