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 May 17-19, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House Pa 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 June 13, 2010.
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Plan of Correction
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715.8(1)(vi) LICENSURE Psychosocial Staffing
A narcotic treatment program shall comply with the following staffing ratios as established in Chapter 704 (relating to staffing requirements for drug and alcohol treatment activities):
(vi) Outpatients. The counseling caseload for one FTE counselor in an outpatient narcotic treatment program may not exceed 35 active patients.
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Observations
Based on the review of administrative documentation and discussion with facility director, the facility failed to maintain counselor caseloads which complied with the staffing in accordance with the regulations.
The findings include:
Administrative documentation that included counselor caseloads was reviewed on May 17, 2010 and an interview with the facility director occurred on May 19, 2010. The facility failed to maintain a counselor caseload which complied with the staffing ratios as established in Chapter 704 for two counselor caseloads reviewed.
One full time counselor had a caseload of 36:1.
One caseload reviewed was listed under the name of a counselor who was no longer employed at the facility. The caseload of this counselor had not been reassigned upon the departure of the counselor. Further review and investigation revealed that 27 patients were not assigned to a counselor. An interview with the facility director confirmed that 27 patients did not have an assigned counselor.
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Plan of Correction
All counselors will maintain a caseload of 35:1 at all times. This will be immediate and on-going. Furthermore, all patients will be assigned to a counselor if/when a counselor leaves/gets terminated from employment. This will be immediate or on-going. Both clinical supervisors will monitor for full compliance throughout the year. |
715.29(4) LICENSURE Exceptions
A narcotic treatment program is permitted, at the time of application or any time thereafter, to request an exception from a specific regulation.
(4) The narcotic treatment program shall maintain documentation of the Department 's approval of an exception.
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Observations
Based on a review of patient records, staffing records, facility documentation and staff interview, the facility failed to maintain compliance with their Division approval for a caseload variance.
The findings include:
The facility requested and received approval to maintain caseloads of no more than fifty to one for qualified staff with caseloads that included patient with reduced psychotherapy requirements. By having this exception, the facility is required to maintain a tracking system that allowed the facility, at any given time, to identify the number of patients included in this formula and the caseloads specifying those on a reduced schedule as well as have established criteria to determine who is appropriate for a reduced schedule under the ratio variance. The active patient case list was reviewed on May 17, 2010.
The facility did not maintain a tracking system that allowed the facility, at any given time, to identify the number of patients included in this formula and the caseloads specifying those on a reduced schedule. The patient list provided documenting of patients who had reduced counseling hours but there was no documentation that revealed the the patients were reviewed to determine whether or not each patient continued to meet the criteria to be maintained on a reduced schedule.
An interview with the facility director and clinical supervisor occurred on May 19, 2010. The facility director and clinical supervisor confirmed that they were able to provide case listings with an identification of the patients currently on a reduced schedule but they were unable to provide documentation that patients were reviewed to determine if they continued to meet the requirements for a reduced schedule.
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Plan of Correction
A two-year review is completed whenever a patient's counseling requirement is going to be reduced. If that patient has a relapse and begins to fail at treatment plan objectives, we have the ability to automatically increase counseling time. This is usually documented in either case consultation notes or individual counseling notes. Regardless, we justify the patient's counseling schedule based upon their progress on their treatment plan. Progress can be documented in either the individual counseling note, or on the treatment plan narrative. Clinical Supervisor will monitor for compliance. This is immediate and on-going. |
715.29(5) LICENSURE Exceptions
A narcotic treatment program is permitted, at the time of application or any time thereafter, to request an exception from a specific regulation.
(5) If the exception relates to a specific patient, the narcotic treatment program shall maintain documentation of the exception in the patient 's record.
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Observations
The facility failed to comply with the conditions of the exception granted by the Division regarding thirteen day take-home privileges in one of two patient records.
The findings include:
Twenty four patient records were reviewed on May 17-19, 2010. Two patient records were reviewed for compliance with the conditions of the exception granted by the Division regarding thirteen day take-home privileges. Patients on thirteen day take home status, based on the exception, must have quarterly call backs (an unscheduled return to the facility within 24 hours) that includes an inventory of patient's remaining take home supply, drug testing or methadone plasma levels, and a review as to whether the reduced take-home schedule should continue. The facility failed to conduct quarterly call backs for patient # 15.
Patient #15 was admitted to the program on June 4, 1990. The patient was receiving thirteen day take home privileges. The patient had documented call backs for May 12, 2009 and August 19, 2009. The patient was required to have call backs in November 2009 and February 2010. There were no documented calls backs for November 2009 or February 2010 in the patient record.
On May 18, 2010 @ 1:45 PM, the facility director reviewed the patient record and confirmed there was no documentation provided that showed the patient had received the required call backs in November 2009 and February 2010.
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Plan of Correction
All thirteen-day status patients will receive quarterly call-backs. The patient's counselor will request a call-back in connection with the take-home review, which is done every 90 days. Clinical Supervisor and Nurse Manager will monitor for compliance. This will be immediate and on-going. |