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 28 and 29, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Lebanon Treatment Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on May 22, 2008.
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Plan of Correction
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715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
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Observations
Based a review of 13 patient records, the facility failed to document the physician's rationale for determining take-home privileges in five patient records; specifically, patients # 1, 2, 3,10, and 11 did not contain documentation by the physician that identified the rationale for determining each patient's take-home status.
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Plan of Correction
As of 05/01/2008, medical director will add his rationale to the case consult completed for the presentation of take home doses at the medical team meeting where the request is reviewed for approval. Nursing Supervisor will monitor for compliance. |
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 a minimum of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment in eight of thirteen records, specifically #1, 3 ,4, 6, 7, 8, 9, and 11. In record #1, the patient received 1 hour of psychotherapy in February 2008. In record # 3, the patient received 1 hour of psychotherapy in February 2008, 2.5 hours in March 2008, and 2 hours in April 2008. In record # 4, the patient received 1.5 hours in February 2008, 1 hour in March 2008, and 1.5 hours in April 2008. In record #6, the patient received 2.25 hours of psychotherapy in February 2008, 2.5 hours in March 2008, and 2 hours in April 2008. A review of patient # 7's record indicated that the patient received 2.25 hours of psychotherapy in February 2008, 2.25 hours in March 2008, and 2 hours in April 2008. Patient # 8 received 3.5 hours of psychotherapy in February 2008, 1 hour in March 2008, and 2 hours in April 2008. Patient # 9's record documented 2.5 hours in February and April 2008 with 2.25 in March 2008. Record # 11 contained documentation of 1.5 hours in February 2008, 2.5 hours in March 2008, and 1.5 hours in April 2008.
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Plan of Correction
As of May 1, for April month, clinical staff will present documentation to clinical supervisor during individual supervision of clinical time spent with patients and will review documentation as well as interventions performed for assisting patients to comply with minimum required attendance for clinical sessions. This will continue on a monthly basis to assist staff in developing clinical skills to address noncompliance issues. Clinical Supervisor will monitor for full compliance. If found to continue to be an issue after a month of review, will address in clinical team for team review to achieve full compliance. |
715.20 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.
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Observations
The facility failed to follow policy and procedure to address patient # 17's request for transfer; specifically, when the patient requested a transfer to another narcotic treatment program, she was informed she could not transfer until she had paid the balance of the money she owed to the facility.
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Plan of Correction
Immediately, transfers will be honored and facilitated with a signed release upon the request of the patient. Documentation for transfer will be completed at the time of the request. This will be monitored for compliance by the clinical supervisor. |
715.21 LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
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Observations
Based on a random review of 7 patient records, the facility failed to follow their policy and procedure regarding patient terminations, specifically patient # 7 was not provided a written notification of the involuntary termination.
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Plan of Correction
Immediately, patient involuntary terminations will be addressed with the patient and provided in writing to the patient for clarity of the reason for the involuntary termination. This will be monitored by the clinical supervisor who will also be responsible for the written documentation of termination. |
715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
Based on the review of patient records, there was no documentation the facility had completed a tuberculosis Mantoux test for one of the thirteen patients reviewed, record # 6.
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Plan of Correction
Immediately, the Nursing Supervisor will review admission charts within 7 days for completion of needed laboratory tests. This will be monitored by the Nursing Supervisor as well as the Clinical Supervisor for full compliance. |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on a review of patient records, it was determined that the facility failed to ensure that the psychosocial evaluation contained a clinical analysis of the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, patient's attitude toward treatment and overall impressions. A review of six psychosocial evaluations identified that in four patient records, specifically records # 6, 7, 8, and 10, the facility failed to document the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, patient's attitude toward treatment and overall impressions based on the clinician's analysis of the collected historical information.
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Plan of Correction
As of May 1, at minimum on a monthly basis during clinical team meetings, the psychosocial process will be reviewed particularly sample psychosocial for practice with clinical assessment. All psychosocial/ interpretive summary completions will be reviewed for the next 3 months, minimally, by the clinical supervisor for sufficient clinical assessment during individual clinical supervision. The clinical supervisor will monitor for compliance. |
715.23(d)(1) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(1) The treatment plan shall identify the behavioral tasks a patient shall perform to complete each short-term goal.
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Observations
Based on the review of patient records, the facility failed to develop treatment plans that contained short term goals with measurable action steps. Further, the treatment plans failed to identify support services needed by the patient. Of the the 13 patient records reviewed, records #1, 2, 3, 6, 7, 8, 9, 10, 12, and 13 contained vague, non-specific steps to reach the gaols and the time frames were generalized rather than realistically specific to the action step; patient records # 1, 2, 3, 6, 7, 8, 9, 10, and 11 did not document available support services that were specific to the identified goals and patient needs.
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Plan of Correction
On June 25, 2008, a training on treatment planning has been scheduled with a CRC trainer regarding the development of treatment plans for the clinical staff. In addition, treatment plan reviews will continue within individual supervision. Also, on a minimum monthly basis, review of treatment plan development will be explored in the clinical treatment team meeting. The clinical supervisor will monitor for full compliance. |
715.23(d)(2) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Based on a review of patient records, the facility failed to document treatment plan updates based on the patient's progress as it relates to the goals stated in the comprehensive treatment plan in seven of thirteen records, specifically #1, 2, 3, 5, 8, 9, and 11. The treatment plan updates failed to address patient specific goals and when new goals were added no interventions or action steps were documented in order to determine measurability.
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Plan of Correction
Immediately, treatment plan updates will be reviewed for addressing patient goals, and new interventions that are measurable. Also, On June 25, 2008, a training on treatment planning has been scheduled with a CRC trainer regarding the development of treatment plans for the clinical staff. In addition, treatment plan reviews will continue within individual supervision. Also, on a minimum monthly basis, review of treatment plan development will be explored in the clinical treatment team meeting. The clinical supervisor will monitor for full compliance. |