INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 19-20, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Polaris Renewal Services, Inc., was found not to be in compliance with the applicable chapters of 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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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 physician timesheets, the facility failed to provide physician services, at least one hour per week for every ten patients, for five of seventeen weeks reviewed.The findings include:Physician time sheets for the months of October, November and December 2014 as well as January 2015 were reviewed on February 19-20, 2015. Five weeks provided insufficient onsite physician hours during November, December and January. During the week of November 2-8, 2014, the patient census was 98. The facility was required to provide at least 9.8 physician hours. There were 8.5 physician hours documented. During the week of November 23-29, 2014, the patient census was 112. The facility was required to provide at least 11.2 physician hours. There were 7.5 physician hours documented. During the week of December 21-27, 2014, the patient census was 121. The facility was required to provide at least 12.1 physician hours. There were 4.5 physician hours documented. During the week of December 28, 2014 - January 3, 2015, the patient census was 123. The facility was required to provide at least 12.3 physician hours. There were 6 physician hours documented. During the week of January 4-10 2015, the patient census was 121. The facility was required to provide at least 12.1 physician hours. There were 9.75 physician hours documented. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Narcotic Treatment Program failed to meet the required on-site Physician hours for the inspected period. The Program Director will schedule the program physician(s)each week to ensure that there is at least one hour of physician coverage for every ten patients. The Program Director will monitor the program census daily to account for increases in census and schedule additional physician hours as needed. In addition, the Program Director will schedule the program's back up physicians to account for any physician time off. The Program Director will review physician hour requirements with the program physicians as well. |
715.16(c)(3)(i-viii) LICENSURE Take-home privileges
(c) A narcotic treatment program shall require a patient to come to the narcotic treatment program for observation daily or at least 6 days a week for comprehensive maintenance treatment, unless a patient is permitted to receive take-home medication as follows:
(3) A narcotic treatment program may permit a patient to reduce attendance at the narcotic treatment program for observation to one time weekly and receive no more than a 6-day take-home supply of medication when in the reasonable clinical judgment of the narcotic treatment physician, which is documented in the patient record:
(i) A patient demonstrates satisfactory adherence to narcotic treatment program rules for at least 3 years.
(ii) A patient demonstrates substantial progress in rehabilitation.
(iii) A patient demonstrates responsibility in handling narcotic drugs.
(iv) A patient demonstrates that rehabilitation progress would improve by decreasing the frequency of attendance for observation.
(v) A patient demonstrates no major behavioral problems.
(vi) A patient is employed, is actively seeking employment, attends school, is a homemaker or is considered unemployable for mental or physical reasons.
(vii) A patient is not known to have abused alcohol or other drugs within the previous year.
(viii) A patient is not known to have engaged in any criminal activity within the previous year.
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Observations
Based on a review of patient records, the facility failed to consider the criteria for granting a 6-day take-home supply of medication in one of one patient record.The findings include:Nine patient records were reviewed on February 19-20, 2015. One patient record was reviewed for a 6-day take-home supply of medication. A narcotic treatment program may permit a patient to reduce attendance at the narcotic treatment program for observation to one time weekly and receive no more than a 6-day take-home supply of medication when specific criteria are met. The facility failed to consider the criteria for granting a 6-day take-home supply of medication in patient record # 5.Patient # 5 was admitted into treatment on November 14, 2014. The patient had transferred into treatment from another narcotic treatment program. His admission date from the other narcotic treatment program was March 8, 2012, giving him 2 years and 8 months in continuous narcotic treatment. The patient was immediately granted privileges for a 6-day take-home supply of medication on his admission date, November 14, 2014. The facility failed to consider the length of time the patient was in treatment before granting a 6-day take-home supply of medication. This patient did not meet the requirement of demonstrating satisfactory adherence to narcotic treatment program rules for at least three years.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Narcotic Treatment Program failed to consider the PA State regulatory criteria for granting take homes to a transfer patient. The Facility Director will meet with clinical staff to reeducate on the regulatory requirements for take home privileges. The Program's nursing staff will complete a review of recent admission, readmissions and transfers into the program within the past ninety (90) days to determine if there were any other affected patients. Monitoring of the admittance process of transfer patients will be continously fulfilled by the Lead Counselor and Nursing Staff. |
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, the facility failed to document an average of 2.5 hours of psychotherapy per month during the patient's first two years, in two of five patient records, as required.The findings include:Nine patient records were reviewed on February 19-20, 2015. Five patient records were reviewed for the completion of an average of 2.5 psychotherapy hours per month. The facility failed to document an average of 2.5 hours of psychotherapy per month in patient records #1 and 2.Patient # 1 was admitted into treatment on November 4, 2014. The patient attended 1.5 hours of psychotherapy in January 2015 and 1.5 hours of psychotherapy in December 2014.Patient # 2 was admitted into treatment on November 19, 2014. The patient attended 1 hour of psychotherapy in January 2015 and 1.5 hours of psychotherapy in December 2014.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Narcotic Treatment Program failed to meet the required 2.5 hours of psychotherapy per month during the patient's first two years of participation in the MMT Program for two patients. The Program Director and Counselors will continue to complete chart audits, quarterly case consults and weekly clinical supervision meetings, reviewing the frequency of treatment, while ensuring that patients are complying to the Program's standards and are fulfilling the required 2.5 hours of psychotherapy per month throughout the patient's first two years of participation in the MMT Program. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on the review facility documentation, the facility failed to file a written Unusual Incident Report with the Department within 48 hours regarding the death of a patient in one of one client records.The findings include:Nine patient records were reviewed on February 19-20, 2015. One of the patients reviewed was deceased. The facility failed to file a written Unusual Incident Report with the Department within 48 hours after the patient's death in patient record #6.Patient #6 was admitted on October 22, 2014 and discharged at the time of her death on December 15, 2014. At the time of the inspection, no unusual incident report was filed with the Department within 48 hours regarding the patient's death.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Narcotic Treatment Program failed to file a written Unusual Incident Report with the Department within 48 hours regarding the death of a patient. The Program Director will report, within 48 hours, all unusual incidents, per PA State regulatory requirements. The Program Director will also provide training to the staff about unusual incident reporting and the time frame for submission to all regulatory bodies, including DDAP. In the absence of the Program Director, the lead counselor will notify the Program Director of the unusual incident and act as the Director's designee to complete and submit the unusual incident report to DDAP. All unusual incident reports will be kept in a file by the Program Director. |