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 March 13-14, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Innovative Recovery Solutions 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.
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Plan of Correction
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715.9(e) LICENSURE Intake
(e) A narcotic treatment program shall secure a personal history from the patient within the first week of admission. The personal history shall be made a part of the patient record.
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Observations
Based on a review of patient records and an interview with a counselor, the facility failed to document a personal history form within the first week of admission, as required by regulation, in five of five patient records.
The findings include:
Twelve patient records were reviewed on March 13-14, 2012. Five of the patients reviewed required the documentation of a personal history, completed within one week of admission. The facility failed to document the personal history within the first week of admission in patient records # 1, 4, 5, 6 and 8.
Patient # 1 was admitted on September 23, 2011. The personal history was completed on October 11, 2011.
Patient # 4 was admitted on December 2, 2011. The personal history was completed on December 14, 2011.
Patient # 5 was admitted on August 11, 2011. The personal history was completed on August 23, 2011.
Patient # 6 was admitted on December 2, 2011. The personal history was completed on December 16, 2011.
Patient # 8 was admitted on May 26, 2011. The personal history was completed on June 4, 2011.
An interview with the project/facility director on March 14, 2012 confirmed the findings.
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Plan of Correction
Facility Director shall provide training by 4/15/2012 and maintain documentation of that training for Clinical Staff Members related to completion of Personal History within 7 days of Admission to treatment for all patients. Facility Director will assist with scheduling as needed and will monitor for compliance. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on the review of patient records, the facility failed to document that random urinalysis were conducted at least monthly in eight of eight patient records.
The findings include:
Twelve patient records were reviewed on March 13-14, 2012. Eight patient records required random urinalysis at least monthly. The facility did not document monthly urinalysis for patient records # 1, 2, 3, 4, 5, 6, 7 and 8.
Patient # 1 was admitted on September 23, 2011. There were no laboratory reports documented for the random urinalysis conducted in November, December, 2011 and January and February, 2012.
Patient # 2 was admitted on November 4, 2010. There were no laboratory reports documented for the random urinalysis conducted in November, December, 2011 and January and February, 2012.
Patient # 3 was admitted on September 30. 2010. There were no laboratory reports documented for the random urinalysis conducted in November, December, 2011 and January and February, 2012.
Patient # 4 was admitted on December 2, 2011. There were no laboratory reports documented for the random urinalysis conducted in November, December, 2011 and January and February, 2012.
Patient # 5 was admitted on August 11, 2011. There were no laboratory reports documented for the random urinalysis conducted in November, December, 2011 and January and February, 2012.
Patient # 6 was admitted on December 2, 2011. There were no laboratory reports documented for the random urinalysis conducted in November, December, 2011 and January and February, 2012.
Patient # 7 was admitted on April 26, 2010. There were no laboratory reports documented for the random urinalysis conducted in November, December, 2011 and January and February, 2012.
Patient # 8 was admitted on May 26, 2011. There were no laboratory reports documented for the random urinalysis conducted in November, December, 2011 and January and February, 2012.
An interview with the project/facility director of March 14, 2012 confirmed the findings.
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Plan of Correction
Beginning 4/1/2012, Medical Staff will maintain a binder in the Dispensary of all faxed urinalysis results provided by the lab which are currently being downloaded directly into the clinical management software. Facility Director will monitor for compliance. |
715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. 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 document that patients received at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment in one of one patient record.
The findings include:
Twelve patient records were reviewed on March 13-14, 2012. One patient record reviewed required the patient to receive at least 1 hour per month of group or individual psychotherapy. The facility did not document 1 hour a month of psychotherapy in patient record # 2.
Patient # 2 was a transfer from another narcotic treatment program and was admitted on November 4, 2010. The patient has been in continuous treatment since November 10, 2009 and requires 1 hour of monthly psychotherapy. The patient had no documented psychotherapy hours for the months of January and February, 2012.
An interview with the project/facility director on March 14, 2012 confirmed the findings.
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Plan of Correction
Facility Director will provide training by 4/15/12 for all Clinical Staff members and maintain documentation of that training related to counseling requirements for patients in treatment based on length of time receiving care. Facility Director will assist with scheduling as needed and will monitor for compliance. |
709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on the review of the policy and procedures manual and patient records, the facility failed to document the written procedure for the management of treatment/rehabilitation services for patients which addressed the timeframe for the development of the patient's individualized treatment plan.
The findings include:
The policy and procedures manual was reviewed on March 13-14, 2012. Twelve patient records were reviewed on March 13-14, 2012. Five patient records were reviewed for the completion of the individualized treatment plan. The policy for the development of the individualized treatment plan did not address the timeframe in which the plan needed to be completed, resulting in the individualized treatment plan being completed within different timeframe for patients # 1, 4, 5, 6 and 8.
Patient # 1 was admitted on September 23, 2011. The individualized treatment plan was completed on December 28, 2011.
Patient # 4 was admitted on December 2 , 2011. The individualized treatment plan was completed on January 2, 2012.
Patient # 5 was admitted on August 11, 2011. The individualized treatment plan was completed on August 12, 2011.
Patient # 6 was admitted on December 2 , 2011. The individualized treatment plan was completed on December 31, 2011.
Patient # 7 was admitted on May 26, 2011. The individualized treatment plan was completed on July 15, 2011.
An interview with the project/facility director on march 14, 2012 confirmed that the facility's policies and procedures did not identify timeframes for the completion of treatment plans.
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Plan of Correction
Facility Director has updated the Policy and Procedure manual to specify timeframes and will provide training for the Clinical Staff Members by 4/15/12 and will maintain documentation of that training related to this policy change. Facility Director will monitor for compliance. |