INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the May 17 - 19, 2010 inspection conducted for the approval to use a narcotic agent, specifically methadone, in the treatment of narcotic addiction. This inspection was conducted on November 15, 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 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 December 10, 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 a review of counselor caseloads and an interview with the facility director, the facility failed to ensure staff caseloads remained at or under 35 active patients per one FTE (Full Time Equivalent) counselor.
The findings include:
On November 15, 2010, fifteen counselor caseloads were reviewed. One counselor is currently on medical leave and her cases have been distributed to the other fourteen counselors. Per regulation, the counseling caseload for one FTE counselor in an outpatient narcotic treatment program may not exceed 35 active patients.
The facility's standard work week, as reported by the facility director, is 40 hours per week. Three counselors are working 42 hours per week and the other twelve are working 40 hours per week. Based on the total number of hours per week that the facility reported the employees devoted to their patients, the total number of hours in the facility's standard work week (40), and the total number of patients assigned to the following employees on November 15, 2010, employees # 1, 2 and 3 exceeded the allowable maximum 35:1 caseload.
The actual patient caseload is determined by dividing the Full Time Equivalent (FTE) into the actual number of patients. The FTE is determined by dividing the number of hours devoted to the patient's treatment by the facility's standard workweek.
The number of hours per week devoted by Employee # 1 to patient treatment, was 42 hours per week. A copy of the counselor's caseload documented 37 active clients were assigned to Employee # 1.
Employee # 1 (42/40 = 1.05 FTE 37 clients/1.05 FTE = 36:1 caseload)
The number of hours per week devoted by Employee # 2 to patient treatment, was 42 hours per week. A copy of the counselor's caseload documented 38 active clients were assigned to Employee # 2.
Employee # 2 (42/40 = 1.05 FTE 38 clients/1.05 FTE = 37:1 caseload)
The number of hours per week devoted by Employee # 3 to patient treatment, was 42 hours per week. A copy of the counselor's caseload documented 37 active clients were assigned to Employee # 3.
Employee # 3 (42/40 = 1.05 FTE 37 clients/1.05 FTE = 36:1 caseload)
During an interview, the facility director confirmed that they had exceeded the allowable maximum caseload of 35:1 for employees # 1, 2 and 3.
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Plan of Correction
Some of our counselors were covering extra patients for a counselor on maternity leave. These counselors were working over time each week to cover the extra time. However, we were not offering enough over time to meet the state's requirements of approx. 75-80 minutes per patient per week of over time. The facility director has corrected this deficiency by authorizing counselors to work overtime to cover the extra assigned cases. We will now offer 80 minutes of overtime per patient per week any time a counselor goes over 35 patients. This will be immediate and ongoing. Clinical Supervisor will monitor for compliance. |
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
Based on a review of patient records and an interview with the facility director, the facility failed to document all components required for an exception in one of two patient records.
The findings include:
Two patient records were reviewed during a plan of correction follow up inspection on November 15, 2010. Two patient records were required to have documentation pertaining to a previously approved exception. The facility failed to comply with the conditions of the exception granted by the Division regarding thirteen day take-home privileges. Patients on a thirteen day status must have quarterly call backs (an unscheduled return to the facility within 24 hours) that included an inventory of the patient's remaining take home supply, a documented review of the patient's status, and drug testing or methadone plasma levels. The facility failed to conduct quarterly call backs for patient # 1.
Patient # 1 was admitted into treatment on January 10, 1995. The facility received a Department approved exception for this patient to receive a thirteen day take-home status. The last documented call back and review of the patient's status was on March 31, 2009. No call backs were conducted for the last three quarters of 2009 or the first three quarters of 2010.
The facility director was interviewed on November 15, 2010. The facility director reviewed patient record # 1 and confirmed that call backs had not been completed on a quarterly basis in 2009 and 2010, as required.
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Plan of Correction
Each 13-day status patient will be reviewed by the clinical supervisor on a quarterly basis either in individual supervision with the counselor or self-audit to monitor for compliance. This is immediate and ongoing. Patient #1 received a call-back on 11/16/10. Discovery House will also be working on adding a quarterly prompt in our software for call-backs on all 13-day status patients. ETA on the prompts is 90 days. Clinical Supervisor will monitor for compliance. |