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 November 12-13, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Progressive Medical Specialists, 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 and a plan of correction is due on December 18, 2009.
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Plan of Correction
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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
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Observations
Based on the review of administrative documentation and staff interviews, the facility failed to provide at least one hour of physician time a week, on site for, every ten patients.
The findings include:
Physicians time sheets and and census reports for the months of August, September, October and November 2009 were reviewed on November 12, 2009. The interview with staff occurred on November 12, 2009. The facility is licensed to medicate 450 patients and the census did not go below 264 patients during the time period reviewed. The physician's hours documented were insufficient for the weeks of August 31, September 7, 14, 21 and 28, 2009.
During the week of August 31, 2009, the total physician time required was 27 hours. The total physician time documented was 24.5 hours.
During the week of September 7, 2009, the total physician time required was 27 hours. The total physician time documented was 25 hours.
During the week of September 14, 2009, the total physician time required was 27 hours. The total physician time documented was 26 hours.
During the week of September 21, 2009, the total physician time required was 27 hours. The total physician time documented was 25.5 hours.
During the week of September 28, 2009, the total physician time required was 27 hours. The total physician time documented was 16.25 hours.
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Plan of Correction
Every Wednesday the medical director and project director will review the hours completed for the week to determine how many hours are needed to ensure the 1 to 10 ratio is met weekly.
A schedule will be created for the remaining days of the week that will ensure the correct number of medical hours is obtained consistently.
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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 the counselor assistants' caseloads, the facility failed to comply with the staffing regulation which states that the counseling caseload for one Full Time Equivalent (FTE) counselor in an outpatient narcotic treatment program may not exceed 35 active patients.
Finding:
The counselor assistants' caseloads were reviewed on November 12-13, 2009. The facility included the counselor assistants in the reduced caseload ratios. Counselor assistants are not eligible for a reduced caseload. Caseloads exceeded 35 to 1 for six of the seven counselor assistants.
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Plan of Correction
From the licensing visit held in August 2009 director had thought counselor client ratios were being completed correctly.
Clinical supervisors and project director removed clients from all counselor assistants who had an active caseload that exceeded the allowed amount of 35 clients.
Clients were placed on caseloads with counseling staff who meet exception requirements.
Counselor supervisors will ensure that counselor assistants maintain a caseload of 35 active clients by using the counselor active caseload list generated by our computer program when assigning new clients, (reviewed at least weekly by clinical supervisors)
Project director will continue to use monthly tracking sheets to complete client counselor ratios. This tracking sheet allows director to review the number of clients assigned to each counselor thus a monthly review of each caseload will be completed to ensure compliance.
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715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
Based on observation and staff interviews, the facility failed to physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR Part 2, Subpart B,
2.22 (relating to notice to patients of Federal confidentiality requirements) and 28 Pa. Code 709.28 (relating to confidentiality).
Findings:
During the observation of the methadone dispensing on November 13, 2009, it was observed that the patients were drawing a black line on their returned take home bottles. The bottles were then placed in a trash can without staff checking the bottles. The trash in this can is placed in with the general trash. Upon removing one of the take home bottles from the trash can, it was observed that the patient had not crossed out their name completely. The patient's first and last names were visible. This practice did not ensure that the patient's confidentiality was physically secure and maintained.
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Plan of Correction
Clients were informed of the importance of crossing out their name on their empty take home bottles, thru information placed in the December newsletter which goes to all clients on the 1st of each month. This reminder will become part of the newsletter every month.
Also, all counselors were informed to discuss this issue with their clients while in session within a 2 week time frame; signs were posted in each counselor office reminding clients to completely mark off their name to ensure confidentiality.
Medical staff were instructed at a meeting with the project director on 11/23/09 to look at all bottles closely and ensure names cannot be read before throwing them in the trash.
Nursing staff members were instructed to give back any bottles to any clients if their name could be seen to further black of the information prior to throwing bottles away
Nurse supervisor will be responsible for monitoring this process daily. Nurse supervisor will look at some of the bottles collected for that day to ensure the names cannot be read.
Any concerns or issues will be addressed daily by the nurse supervisor with the medical staff and a note regarding the issue will be documented on the daily report to project director so it can be followed up with.
Project and medical director will complete unannounced checks once a month by checking the bottles in the trash. Findings of these unannounced inspections will be added to our monthly medical report.
Any issues will be documented and addressed the day they are found.
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715.14(b) LICENSURE Urine testing
(b) A narcotic treatment program shall develop and implement policies and procedures to ensure that urine collected from patients is unadulterated. These policies and procedures shall include random observation which shall be conducted professionally, ethically and in a manner which respects patient privacy.
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Observations
Based on the review of the facility's policy and procedures, staff interviews and observation, the facility failed to follow policies and procedures to ensure that urine samples collected from patients is unadulterated.
Findings:
The observation of the dosing area was conducted at approximately 9:30 am on November 13, 2009. During the observation period, four patients were required to give random urine samples. The facility's policy and procedures state that the nursing staff will observe the patient providing the urine sample. The patient will then give the sample to the nurse who will check the temperature of the sample. The nurse will make sure the bottle and the bag are sealed and that the information on the bag and bottle match.
Observation of the collection of the urine samples showed that the nurse did not collect the sample from the patient, the nurses did not check the temperature, nor ensure that the bottles and bags were sealed. The identifying information on the bottles and bags were not checked for matches at the time the urine samples were submitted. The urine samples were placed by the patient, with some bottles and bags unsealed, in a bin which was accessible to other patients and personnel.
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Plan of Correction
The project director spoke with nursing staff on November 13, 2009. Director agreed that staff were not following procedure regarding urine specimen collection.
As a result, the project director reviewed policy and procedures with medical staff on November 23, 2009. To ensure an understanding of the process for obtaining urine samples from a client.
Project and medical director will monitor nursing staff to ensure that procedures are used consistently.
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715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on the observation of the administration of medication, the facility failed to administer and dispense the medication in a manner that protected the patient from disruption or annoyance from other individuals.
Findings:
The observation of the administration of medication occurred on November 13, 2009 at approximately 9:30 am. During the observation period, the dispensing was not administered in a manner that protected the patient from disruption or annoyance from other individuals.
The following observations were noted:
A patient was at the dosing window when another patient came to the window and was handed an empty urine sample bottle through the same dosing window by the dispensing staff.
A patient at the dosing window and another patient waiting to use the restroom were engaging in conversation.
Patients at both dosing windows were engaging in conversation with each other. The one patient then went over to the other patient's window to view a lock box this patient had.
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Plan of Correction
Clients were informed of dosing procedures via the monthly newsletter. This will become part of the newsletter every month.
On 11/23/09 counselors were instructed to tell their clients within a two week period that they cannot do anything at the dosing window except dose and speak to the nursing staff.
Clinical staff were reminded that they cannot talk with any client while they are in the dosing area.
On 11/23/09 front office staff were instructed by project director to not allow clients to speak to them through the side window by the dosing area. That the front office staff will be responsible for having the client return to the front counter to ask questions of staff.
On 11/23/09 nursing staff were instructed to monitor and control client's behavior at the dispensing window. Nursing staff members will be required to make sure that only one client is at the window and that they are dealing with one client at a time.
Project director and medical director will monitor the dispensing area periodically to ensure compliance by the nursing staff.
As well as the nurse supervisor has been instructed to ensure that there are no distractions at the dispensing windows and she is responsible for holding her staff accountable to procedure.
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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 provide each patient with the minimal requirement of an average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment.
Findings:
Fourteen patient records were reviewed on November 12-13, 2009. Six patient records were required to have an average of 2.5 hours of psychotherapy per month during the patient's first 2 years. Patient records # 5 and 9 were missing documentation that the patient had received an average of 2.5 hours of psychotherapy per month.
Patient record # 5 documented an average of 2.08 hours.
Patient record # 9 documented an average of 1.25 hours.
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Plan of Correction
It was decided that the clinical supervisor will meet with each counselor/counselor assistant after the first full two weeks of each month to review their monthly tracking sheets.
Currently, each clinical staff member monitors due dates, counseling time etc, for each client on their caseload on a monthly tracking sheet that is turned into the director the first of each month.
The clinical supervisor can quickly review each client's counseling time completed to date and be able to indentify those client that are not receiving the required amount of counseling time, thus allowing each counselor at least two weeks to ensure compliance with the individual's counseling time.
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715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. 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 provide each patient with at least 1 hour of group or individual psychotherapy every 2 months after 4 years of treatment.
The findings include:
Fourteen patient records were reviewed November 12-13, 2009. One patient record was reviewed for at least one hour of group or individual psychotherapy every 2 months.
In patient record #6, the patient was required to have 1 hour of psychotherapy for the month of August, 2009. Documentation shows the patient received 15 minutes of psychotherapy for the month of August, 2009.
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Plan of Correction
It was decided that the clinical supervisor will meet with each counselor/counselor assistant after the first full two weeks of each month to review their monthly tracking sheets.
Currently, each clinical staff member monitors due dates, counseling time etc, for each client on their caseload on a monthly tracking sheet that is turned into the director the first of each month.
The clinical supervisor can quickly review each client's counseling time completed to date and be able to indentify those client that are not receiving the required amount of counseling time, thus allowing each counselor at least two weeks to ensure compliance with the individual's counseling time.
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715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on review of administrative documentation provided during the inspection and staff interviews, the facility failed to submit documentation of Unusual Incident to the Department as required.
Findings:
The facility had a death of a patient due to a car accident. The facility did not provide documentation that an Unusual Incident Report had been submitted to the Department as required.
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Plan of Correction
All supervisors contact the director when any incident occurs. All managers are aware of standard 715.28(a)-(c) as a result they can identify and report any unusual incidents to director.
If the project director could not be reached (out of town etc) the clinical supervisor of the location will be responsible to report the unusual incident to the State Department of Health and ownership as per policy. Documentation of this would be left for the director for review and follow up.
Project director will ensure that all paperwork to show that required unusual incidents reports are completed and sent to State Department of Health. These forms will be filed in the client's chart, including the fax transmittal sheet to verify it was sent.
The project director completes all unusual incidents reports within 24 hours of finding out about the incident and faxes the report to the Department. If follow up or additional information is received by the facility an updated incident report will be completed by the project director and sent to the Department within 24 hours of receiving the new information.
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