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 April 6-8, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Esper Treatment Center 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 May 2, 2009.
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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 the individual counselor caseloads, the facility failed to provide caseloads below the required 35 patient to one counselor.
The findings include: The caseloads for five counselors were reviewed on April 7, 2009. All five counselors were required to have a caseload that did not exceed 35 patients. Three counselors have a caseload that exceed 35 patients. One counselor had a caseload of 40 patients. One counselor had a caseload of 36 patients. One counselor had a caseload of 36 patients.
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Plan of Correction
The Esper Treatment Center has submitted and exception for the patient client ratio. We have several patients that are eligible for the reduced counseling schedule. We are asking that the ratio be raised to 45 patients to 1 counselor. We also placed an ad in the Erie Times News for a drug and alcohol counselor. With the both of the actions in place that will ensure that the counselors are not over on their caseloads. The Esper Treatment Center hopes to fill the counseling position within 3 weeks after the ad has been run. The Clinical Director will ensure that the proper person is hired for the position with the proper degree and experience. |
715.16(a)(4) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(4) A narcotic treatment physician may rescind take-home medication privileges.
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Observations
Based on a review of patient records, the facility failed to document the rescinding of take- home medication privileges in one of one record.
The finding include:
Thirteen patient records were reviewed on April 7 and 8, 2009. One record was required to have documentation regarding the rescindment of take home medication privileges. Patient record #5 did not contain physician documentation for the rescindment of take home medication privileges. A review of the patient record revealed an order granting one day take home privileges was written on 10-23-08. The record further revealed subsequent orders and documentation, dated 12-5-08 and 1-14-09, that indicated the patient did not have take-home privileges. In interviews with the director on 4-7-09 and 4-8-09, it was determined the patient had one day take-home privileges that had been revoked, however, the physician had failed to document the rescindment of take-home medication privileges for this patient.
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Plan of Correction
To ensure compliance with the regulation if a patient's take home status is to be changed in any way the counselor will document on the physicians request form the reason for the change in status. The physician will review and write an order reflecting the change in take out status. The counselors will notify the Clinical Director of any changes in take out status and the Nursing Supervisor will ensure that the doctor has signed off on the physicians request and doctors orders. |
715.20(4) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to document notification to the transferring facility of a patient's admission into treatment and date of their initial dose in one of two records.
The finding include:
Thirteen records were reviewed on April 7-8, 2009. Patient transfer information was required in two patient records. Patient record #10 did not include documentation that the facility notified the transferring facility of the patient's admission into treatment and date of initial dose.
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Plan of Correction
To ensure compliance with the regualtion the Clincal Director has formulated a letter informing the facility that the patient has transferred and dosed at our facility. The Administrative Assistant will ensure that this letter is faxed to the transferring facility at the patients intake. The confirmation fax will be attached to the original letter and kept in the patients clinical file. |