INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 19, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center for Addictive Disease - Main Line Affiliates 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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715.19(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 1 hour of individual psychotherapy per month in two of two patient records reviewed.The findings include:On September 19, 2013, two patient records requiring documentation of 1 hour of individual psychotherapy per month were reviewed. The facility did not document 1 hour of individual psychotherapy per month in two of two records reviewed, specifically, patient records # 1 and 3.Patient # 1, a suboxone patient, was admitted April 10, 2013 and prescribed suboxone on May 29, 2013. The facility was required to provide 1 hour of individual psychotherapy per month after the patient was prescribed suboxone on May 29, 2013. However, patient record # 1 did not include documentation of individual psychotherapy as of September 19, 2013.Patient # 3, a suboxone patient, was admitted December 17, 2012 and prescribed suboxone on January 17, 2013. The facility was required to provide 1 hour of individual psychotherapy per month after the patient was prescribed suboxone on January 17, 2013. However, patient record # 3 did not include documentation of individual psychotherapy as of September 19, 2013. The findings were confirmed during an interview with the facility director on September 19, 2013 at approximately 4:00 P.M.
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Plan of Correction
Patients 1 and 3 will attend individual appointments the week of November 4th. Patients 1 and 3 will be assigned to an individual therapist by their program therapist during the week of October 28th. A program will be developed by the clinical supervisor with specific plans for clients to work on issues related to their suboxone use. The individual appointments of clients 1 and 4, and each individual session for all other suboxone clients will be documented in the chart by the therapist who conducts the session. This documentation will be audited during the monthly audit by the auditor. Every other suboxone client will be assigned an appointment that they will attend during the month of November during the week of November 4th by their program therapist and each new client will be assigned an individual appointment at the time they sign the contract for the program with the suboxone coordinator. Moving forward, the clinical supervisor will be responsible for making sure all existing and new suboxone clients during their first two years will receive at least 1 hour of individual psychotherapy per month. |
711.91(b)(5) LICENSURE Physical Examination
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Based on a review of patient records, the facility failed to document a physical examination in three of three patient records reviewed. The findings include:On September 19, 2013, three patient records requiring documentation of a physical examination were reviewed. The facility did not document a physical examination in three of three records reviewed, specifically, patient records # 1, 2, and 3. Patient # 1, a suboxone patient, was admitted April 10, 2013 and prescribed suboxone on May 29, 2013. A physical examination was due prior to the patient being prescribed suboxone on May 29, 2013. However, patient record # 1 did not include documentation of a physical examination as of September 19, 2013.Patient # 2, a suboxone patient, was admitted July 16, 2013 and prescribed suboxone on August 22, 2013. A physical examination was due prior to the patient being prescribed suboxone on August 22, 2013. However, patient record # 2 did not include documentation of a physical examination as of September 19, 2013.Patient # 3, a suboxone patient, was admitted December 17, 2012 and prescribed suboxone on January 17, 2013. A physical examination was due prior to the patient being prescribed suboxone on January 17, 2013. However, patient record # 3 did not include documentation of a physical examination as of September 19, 2013. The findings were confirmed during an interview with the facility director on September 19, 2013 at approximately 4:00 P.M.
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Plan of Correction
Medical director of the facility was given requirements for physicals and is developing a form. The clients were surveyed by their therapists to determine who had a physical in the last six months. Clients 1,2,and 3 and all other suboxone clients will be given the form for their physical examination by their theripists to take to their physicans for completion of the physical examination or given to their physican when having a current physical examination. The date clients were given the form for the physical examination will be recorded in the chart by the therapists. The physical examination will be completed by November 1 for clients 1,2,and 3 and the physical examination forms need to be returned and in the chart by November 1,2013 for all other suboxone clients and for clients 1, 2, and 3. New clients will be given the physical examination form when they are completing their contract by the suboxone coordinator and the physical examination form must be returned prior to their first appointment with the doctor for induction. The suboxone coordinator will make sure that all new suboxone patients will receive a physical examination prior to their appointment for induction with the doctor. |
711.93(a)(6) LICENSURE Aftercare Plans
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of patient records, the facility failed to document an aftercare plan in two of two patient records reviewed. The findings include:On September 19, 2013, two patient records requiring documentation of an aftercare plan were reviewed. The facility did not document an aftercare plan in two of two records reviewed, specifically, patient records # 9 and 10. Patient # 9 was admitted December 31, 2012 and was discharged February 12, 2013. The aftercare plan was due February 12, 2013. However, patient record # 9 did not include documentation of an aftercare plan as of September 19, 2013.Patient # 10 was admitted December 12, 2012 and was discharged February 14, 2013. The aftercare plan was due February 14, 2013. However, patient record # 10 did not include documentation of an aftercare plan as of September 19, 2013. The findings were confirmed during an interview with the facility director on September 19, 2013 at approximately 4:00 P.M.
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Plan of Correction
A staff meeting was held on October 3, 2013 the requirements of discharge and aftercare plans were reviewed. The successful discarges will be reviewed monthly by the clinical supervisor for compliance for six months and then quartely. Completion date October 21, 2013 |