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 and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on September 19, 20, 23, and 24, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, A.R.S. of Lancaster, LP 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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715.15(a) LICENSURE Medication Dosage
(a) The narcotic treatment physician shall review the dosage levels at least twice a year, with each review occurring at least 2 months apart, to determine a patient 's therapeutic dosage.
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Observations
Based on a review of patient records, the narcotic treatment physician failed to document the dosage levels were reviewed at least twice a year, with each review occurring at least two months apart, to determine the patient's therapeutic dosage.
The findings include:
Twenty-eight patient records were reviewed on September 20, 23, and 24, 2013. Sixteen patient records were reviewed for documentation from the narcotic treatment physician's review of the patient's therapeutic dosage level. Three of sixteen records failed to include documentation that the narcotic treatment physician reviewed the patient's dosage level at least twice a year, specifically patient records # 8, 9, and 21.
Patient record #8 revealed the narcotic treatment physician conducted a dosage review on May 21, 2012 and June 25, 2012. The narcotic treatment physician failed to document a dosage review at least two months apart in 2012.
Patient record # 9 revealed the narcotic treatment physician conducted a dosage review on August 15, 2013 and August 30, 2013. The only dose review documented in 2012 was documented on September 18, 2012. The narcotic treatment physician failed to document a dosage review at least two months apart in 2012.
Patient record #21 revealed the narcotic treatment physician conducted a dosage review on January 17, 2012. The narcotic treatment physician failed to document a dosage review at least two months apart in 2012.
This finding was reviewed with the Director of Nursing and was not disputed.
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Plan of Correction
ARS medical director/physician will review dosage levels for all patients at least twice a year, with each review occurring at least 2 months apart, to determine a patient's therapeutic dosage. The physicians will utilize methasoft to schedule and track the review of dosage levels to ensure that the reviews occur according to the regulations. Compliance with this procedure will be monitored by the director of nursing through a monthly audit of patient records. |
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 document an average of 2.5 hours of psychotherapy per month during the patient's first two years, in nine of fifteen patient records, as required.
The findings include:
Twenty-eight patient records were reviewed on September 20, 23, and 24, 2013. Fifteen patient records were reviewed for the completion of an average of 2.5 psychotherapy hours per month. Per regulation, 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. The facility failed to document an average of 2.5 hours of psychotherapy per month in patient records # 1, 2, 6, 12, 13, 15, 17, 18 and 25.
Patient # 1 was admitted on December 12, 2012. The average therapy hours were reviewed for the months of June, July and August 2013. The patient averaged 1.83 hours of psychotherapy per month for the three months reviewed.
Patient # 2 was admitted on May 15, 2013. The average therapy hours were reviewed for the months of June, July and August 2013. The patient averaged .33 hours of psychotherapy per month for the three months reviewed.
Patient # 6 was admitted on December 10, 2012. The average therapy hours were reviewed for the months of June, July and August 2013. The patient averaged 2 hours of psychotherapy per month for the three months reviewed.
Patient # 12 was admitted on April 18, 2013 and discharged on September 11, 2013. The average therapy hours were reviewed for the months of June, July and August 2013. The patient averaged 1.41 hours of psychotherapy per month for the three months reviewed.
Patient # 13 was admitted on March 8, 2012 and discharged on February 18, 2013. The average therapy hours were reviewed for the months of November and December of 2012 and January 2013. The patient averaged 2.83 hours of psychotherapy per month for the three months reviewed.
Patient # 15 was admitted on February 28, 2012 and discharged on February 4, 2013. The average therapy hours were reviewed for the months of November and December of 2012 and January 2013. The patient averaged .66 hours of psychotherapy per month for the three months reviewed.
Patient # 17 was admitted on May 9, 2013. The average therapy hours were reviewed for the months of June, July and August 2013. The patient averaged 1.33 hours of psychotherapy per month for the three months reviewed.
Patient # 18 was admitted on March 6, 2013. The average therapy hours were reviewed for the months of June, July and August 2013. The patient averaged .83 hours of psychotherapy per month for the three months reviewed.
Patient # 25 was admitted on January 28, 2013. The average therapy hours were reviewed for the months of July and August 2013. The patient averaged 1 hour of psychotherapy per month for the two months reviewed.
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Plan of Correction
The counselors were trained by the clinical supervisor on 9/30/13 to place hard stops on patients the last two weeks of the month using the methasoft system to ensure all patients who are noncompliant with counseling hours are met with and complete their requirements for the month. All missed counseling appointments will be documented within the patient record.
To ensure compliance for the next 6 months, the clinical supervisor will review with each counselor monthly that each patient received the minimum 2.5 hours of psychotherapy per month for the first 2 years of treatment.
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715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on the review of patient records, the facility failed to transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient in one of two patient records reviewed.
The findings include:
Twenty-eight patient records were reviewed on September 20, 23, and 24, 2013. Two records required the facility to send the receiving facility patient record information that included admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient. The facility failed to send all the required information in patient record # 12.
Patient # 12 was admitted on April 18, 2013 and was transferred to another treatment program on September 11, 2013. Based on the documentation reviewed in the patient record, the facility failed to send the psychosocial summary to the treatment program the patient transferred.
This finding was discussed with the facility director and was not disputed.
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Plan of Correction
The clinical supervisor trained the counselors on 9/30/13 that when transferring a patient to another agency the following information must be sent, admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient, regardless of what the agency is requesting.
The clinical supervisor will ensure that this process is being completed for transfer but completing random audits of all transfer records for the next six months.
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