INITIAL COMMENTS
|
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 June 5-7, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center for Behavioral Health -Pa, Inc 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.
|
Plan of Correction
|
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
|
Observations
Based on a review of physician and CRNP timesheets, the facility failed to document treatment physician services at least 1 hour per week onsite for every ten patients.
The findings include:
On June 6-7, 2013, the physician and CRNP hours were reviewed for the months of January, February, March, April and May 2013. 12 of the 21 weeks reviewed did not have sufficient physician hours based on the census that week.
January 7-11, 2013 had a census of 318 patients which would require 31.8 physician hours. The facility documented 28.35 physician hours.
January 14-18, 2013 had a census of 325 patients which would require 32.5 physician hours. The facility documented 28.44 physician hours.
January 28 - February 1 , 2013 had a census of 324 patients which would require 32.4 physician hours. The facility documented 28.35 physician hours.
February 4-8, 2013 had a census of 320 patients which would require 32 physician hours. The facility documented 29.96 physician hours.
February 11-15, 2013 had a census of 323 patients which would require 32.3 physician hours. The facility documented 26.83 physician hours.
February 25-March 1, 2013 had a census of 321 patients which would require 32.1 physician hours. The facility documented 30.28 physician hours.
March 4-8, 2013 had a census of 323 patients which would require 32.3 physician hours. The facility documented 30.49 physician hours.
March 11-15, 2013 had a census of 322 patients which would require 32.2 physician hours. The facility documented 30.14 physician hours.
March 18-22, 2013 had a census of 326 patients which would require 32.6 physician hours. The facility documented 29.92 physician hours.
March 25-29, 2013 had a census of 326 patients which would require 32.6 physician hours. The facility documented 26.78 physician hours.
April 1-5, 2013 had a census of 321 patients which would require 32.1 physician hours. The facility documented 25.68 physician hours.
May 6-10, 2013 had a census of 330 patients which would require 33 physician hours. The facility documented 26.65 physician hours.
|
Plan of Correction
In order to ensure Discovery House Cranberry provides 1 hour per week of onsite physician services for every 10 patients, the census will be reviewed weekly and compared to physician hours. The Medical Director and CRNPs will be alerted to census changes and will adjust the schedule to comply with regulations. Program Manager will monitor weekly timesheet and census, Program Director will oversee. |
715.23(b)(22) LICENSURE Patient records
(b) Each patient file shall include the following information:
(22) Aftercare plan, if applicable.
|
Observations
Based on a review of patient records, the facility failed to document an aftercare plan for successfully discharged patients in two of three patient records.
The findings include:
Nineteen patient records were reviewed on June 5-7, 2013. Three of the patients reviewed successfully completed treatment and required documentation of an aftercare plan. There was no aftercare plan completed for patients #17 and #19 after it was decided that they would be successfully discharged.
Patient #17 was admitted on June 5, 2009 and discharged on February 21, 2013. There was no aftercare plan completed for this patient once the decision was made to successfully discharge this patient.
Patient #19 was admitted on March 4, 2009 and discharged on January 2, 2013. There was no aftercare plan completed for this patient once the decision was made to successfully discharge this patient.
An interview with the facility director took place on June 7, 2013 at which time the aforementioned information was confirmed.
|
Plan of Correction
To ensure Discovery House Cranberry documents an aftercare plan for patients who plan to leave treatment successfully, the clinical supervisor will discuss patients who are actively leaving treatment during the weekly case consultation meeting. The patient record will be reviewed and an aftercare plan will be prompted to be completed prior to patient's discharge. Program Director will oversee. |