INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 8 through November 10, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, PA Associates, LLC d/b/a Mount Pocono Medical was found not to be in compliance with the applicable chapters of 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 11, 2010.
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Plan of Correction
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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records and a discussion with the project director it was determined that the facility failed to insure that the staff person appointed to the project director position met the appropriate educational requirements.
The findings include:
A review of the personnel record for Employee #1 indicated that the documentation for educational requirements for the position of project director position were insufficient. The documentation indicated that Employee #1 has a Master of Arts degree however the diploma did not specify the specific degree and no transcripts were provided at the time of the licensing inspection.
An interview with Employee #1 on November 8, 2010 confirmed that the documentation presented did not meet the requirements in the licensing alerts and that transcripts from the employee's school would be forwarded to the employee within 7 days to document the major course of study.
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Plan of Correction
Project Director transcripts received and on file. A review of course content is consistent with state requirements, meeting all requirements in licensing alerts.
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the staffing requirements facility summary report form completed by the facility on November 9, 2010, and an interview with the facility director, the facility failed to ensure that counselor outpatient caseloads were at or below 35 active clients per one Full Time Equivalent (FTE) counselor.
The findings included:
On November 9, 2010, four counselor outpatient caseloads were reviewed on the facility summary report form. Per regulation, the caseload for counseling in outpatient programs may not exceed 35 clients per one FTE counselor. Based on the number of hours the employees worked at this facility, and the number of clients on the counselors' caseload, one counselor exceeded the maximum outpatient caseload of 35:1. Counselor #4 had a caseload of 40:1.
This was discussed with facility director and project director on November 10, 2010. Although overtime hours were added into the calculation, the counselor caseload was still over the 35 active clients per one Full Time Equivalent (FTE)counselor.
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Plan of Correction
Facility Director will track census and staff composition and hire additional staff prior to census need as a means to alleviate increases in FTE caseloads. In the instance of unforeseeable events that may require increases in FTE caseloads, Facility Director will ensure implementation of the appropriate overtime hours utilizing the state formula to meet client/counselor ratios to comply with regulations. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records and a discussion with the facility director and project director, the facility failed to document the instruction of staff in the use of the fire extinguisher upon staff employment, in one of nine personnel records.
The findings include:
Nine personnel records were reviewed on November 9, 2010. nine employees required fire extinguisher training upon employment. Per regulation, the outpatient facility shall instruct staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel record # 1.
Employee # 1 is the project director of the program. The project director was hired on August 2, 2010. There was no documentation that employee # 1 completed fire extinguisher training.
The facility director did mail a copy of the completed training form into the Division office on November 15, 2010 documenting that the training had been completed on August 2, 2010. However, this documentation was not made available during the licensing inspection of November 8 through November 10, 2010.
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Plan of Correction
Documentation of fire extinguisher training is on file. HR chart for employee #1 is now located on site at Miner's Medical to enure availability of necessary documentation in future audits. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill logs and a discussion with the project director and facility director, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill logs were reviewed on November 9, 2010. Fire drill logs were reviewed from March 2010 through November 2010. Per regulation, the nonresidential facility shall prepare alternate exit routes to be used during fire drills. The facility did not document any alternate exits used during fire drills. The front door was the exit route used during every fire drill.
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Plan of Correction
Monthly fire drills will be conducted with activated fire alarm. Facility Director will notify the alarm company prior to simulated drill and obtain documentation from the alarm company to be maintained in fire drill log. Facility Director will be responsible for conducting monthly fire alarms and will instruct the staff and/or patients to use alternative exit routes during the drills ensuring compliance with this regulation.
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill logs and a discussion with the facility director, the facility failed to activate a fire alarm or smoke detector during each fire drill.
The findings include:
The fire drill logs were reviewed on November 9, 2010. Per regulation, the nonresidential facility shall set off a fire alarm or smoke detector during each fire drill. The fire drill log was reviewed for documentation of fire drills from the time period of April 2010 to November 2010. The facility failed to document on the fire drill logs that a smoke detector or fire alarm had been activated for any of the fire drills.
This was discussed with facility director on November 8, 2010. The facility director confirmed that the fire alarm or smoke detector was not activated each month. .
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Plan of Correction
Monthly fire drills will be conducted with activated fire alarm. Facility Director will notify the alarm company prior to simulated drill and obtain documentation from the alarm company to be maintained in fire drill log.
Facility Director will be responsible for conducting monthly fire alarms and ensuring compliance with this regulation. |
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 review of patient records, the facility failed to demonstrate the physician made the determination of the patient's dose in three of four patient records.
The findings include:
Seven patient records were reviewed on November 9, 2010. Three patient records were reviewed for physician's documentation of the patient's initial and subsequent dose and schedule.
In patient records # 4, 6, and 7 a standard order was used for the initial order of 30 mg. However in each of the physician's orders after the initial order was written, the orders were standardized giving 5 mg increases on a daily basis without physician review. All the orders stated "increase 5 mg a day during the first week and review as needed". Subsequent orders stated "increase every 4 days to a maximum dose of methadone (specific mg noted in order) as needed daily and review as needed".
On September 4, 2007, all narcotic treatment programs were issued a letter regarding the use of standard orders, especially during the induction phase, by the Department of Health & Human Services, Substance Abuse and Mental Health Services Administration: (SAMHSA)
In part, the following is excerpted from the letter:
"Because methadone overdose deaths have occurred in early treatment due to the drug's
cumulative effects of the first several days, it is also important to be cautious when
adjusting the dose. According to the drug labeling, the peak respiratory depressant
effects of methadone typically occur later and persist longer than its peak analgesic effects, which can contribute to cases of iatrogenic overdose, particularly during treatment initiation and dose titration. With repeated dosing, "methadone may be retained in the liver and released slowly, prolonging the duration of action despite low plasma concentrations." The drug labeling also states that "steady-state concentrations are not usually attained until 3 to 5 days of dosing," and that doses "will 'hold' for a longer period of time as tissue stores of methadone accumulate." Therefore, patients should be closely monitored during the induction phase, and the increase in dose should be under the close supervision of a physician as stated in 42 CFR 8.12 (h)(4), ' Dosing and administration decisions shall be made by a program physician familiar with the most up-to-date product labeling'. "
In a discussion with the facility director and project director on November 10, 2010 it was stated that the use of a standing order had been reviewed and revised, however after a review of the orders in the patient records documentation indicated that the physician continued to use a standing order.
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Plan of Correction
Project director and Facility director reviewed medication orders deficiency on November 30 and December 2, 2010 with Medical director and physician. In accordance with best practice that during the induction phase all increases of doses will be under the close supervision of the Physician.
Physician orders will be written for each dose adjustment. Physician appointments will be utilized when possible. When a physician is not available on site and an adjustment is needed, nursing will conduct an assessment, including a symptom checklist and/or Cows inventory. The physician will review this information and give a faxed or verbal order for the new dose which will be signed within 24 hours |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the administrative policy and procedures manual and an discussion with the project director and facility director, the facility failed to document psychosocial evaluations that included a clinical assessment of the client in seven client records, as required by regulation.
The findings include:
Seven client records were reviewed on November 9, 2010. Seven client records required the completion of psychosocial evaluations, per regulation. Seven client records did not include a clinical assessment of the client; and only included client historical information. The facility failed to document a psychosocial evaluation that included a clinical assessment in client records # 1, 2, 3, 4, 5, 6, and 7.
Client # 1 was admitted on June 23, 2010. The date of the psychosocial evaluation is 6/23/10. The psychosocial evaluation did not include a clinical assessment of the client; and only included client historical information.
Client # 2 was admitted on May 25, 2010. The date of the psychosocial evaluation is 5/26/10 The psychosocial evaluation did not include a clinical assessment of the client; and only included client historical information.
Client # 3 was admitted on April 21, 2010 . The psychosocial evaluation was completed on April 21, 2010. The psychosocial evaluation did not include a clinical assessment of the client; and only included client historical information.
Client # 4 was admitted on July 13, 2010. The psychosocial evaluation was completed on July 14, 2010. The psychosocial evaluation did not include a clinical assessment of the client; and only included client historical information.
Client # 5 was admitted on April 12, 2010. The psychosocial evaluation was completed on April 14, 2010. The psychosocial evaluation did not include a clinical assessment of the client; and only included client historical information.
Client # 6 was admitted on July 28, 2010. The psychosocial evaluation was completed on July 28, 2010. The psychosocial evaluation did not include a clinical assessment of the client; and only included client historical information.
Client # 7 was admitted on August 17, 2010. The psychosocial evaluation was completed on August 18, 2010. The psychosocial evaluation did not include a clinical assessment of the client; and only included client historical information.
A review of the findings were discussed with the project director and facility director on November 9, 2010. Both confirmed that the system currently being used does not document a psychosocial evaluation that includes all elements required by regulation.
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Plan of Correction
On 11/18/2010 all counseling staff were instructed by the project director in narrative interpretive summary that are grounded in counseling assessment skills. Beginning December 13, 2010 counselors will begin writing interpretive summaries as an assessment and Tower will no longer be utilized. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, and a discussion with the project director and facility director, the facility failed to provide written documentation of the proposed type of support service, in the individual treatment and rehabilitation plans, in seven of seven client records.
The findings include:
Seven client records were reviewed on November 9, 2010. The individual treatment and rehabilitation plans were required to document proposed type of support services in seven client records. The facility did not document proposed type of support services in client records # 1, 2, 3, 4, 5, 6, and 7.
Client # 1 was admitted on June 23, 2010. The individual treatment and rehabilitation plan was completed on July 20, 2010. There was no documentation of support services in the treatment plan.
Client # 2 was admitted on May 25, 2010. The individual treatment and rehabilitation plan was completed on June 17, 2010. There was no documentation of support services in the treatment plan.
Client # 3 was admitted on April 21, 2010. The individual treatment and rehabilitation plan was completed on April 21, 2010. There was no documentation of support services in the treatment plan.
Client # 4 was admitted on July 13, 2010. The individual treatment and rehabilitation plan was completed on July 20, 2010. There was no documentation of support services in the treatment plan.
Client # 5 was admitted on April 12, 2010. The individual treatment and rehabilitation plan was completed on April 15, 2010. There was no documentation of support services in the treatment plan.
Client # 6 was admitted on July 28, 2010. The individual treatment and rehabilitation plan was completed on August 24, 2010. There was no documentation of support services in the treatment plan.
Client # 7 was admitted on August 17, 2010. The individual treatment and rehabilitation plan was completed on September 16, 2010. There was no documentation of support services in the treatment plan.
A review of the findings were discussed with the project director and facility director on November 9, 2010. Both confirmed that the system currently being used does not contain documentation of support services as required by regulation.
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Plan of Correction
The Project Director will instruct clinical staff on Effective Treatment Planning to ensure that an accurate account of client support services is included in the plan by 12/15/10. In addition, treatment plans will be changed from a computer generated format to a more individualized template by 12/13/10. |
709.94(e) LICENSURE Project management services
709.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of the administrative policies and procedures on November 8, 2010 and a discussion with the facility director and project director, it was determined the facility follow-up policy does not reflect actual practice.
The findings include:
The facility follow-up policy stated that "where patients are not referred after discharge, and with prior consent, an attempt will be made to follow-up the ex-patient's progress and status. This contact will be attempted by phone within the first three months following discharge and again between six to twelve months following discharge." This policy does not reflect the practice of how follow up is completed at the facility. This was discussed with the facility director and project director on November 10, 2010 and both confirmed that the policy does not reflect actual practice.
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Plan of Correction
As as November 15, 2010, Regional Director re-wrote the organizational policy to reflect practice of 1x follow-up within 30 days after discharge via phone/mail with prior consent of client. Facility Director will ensure compliance. |