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 August 24-25, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHJ Medical 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 September 19, 2010.
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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 active patient case lists, the narcotic treatment program monitoring questionnaire, and an interview with the facility director, the facility failed to maintain one FTE (full time equivalency) counselor for every 35 active patients.
The findings include:
On August 24 - 25, 2010, the narcotic treatment program monitoring questionnaire and active patient case lists were reviewed. Per regulation, the counseling caseload for one FTE counselor in an outpatient narcotic treatment program may not exceed 35 active patients. The current census of the facility is 277 patients; there are 249 active patients who are assigned to counselor caseloads. The facility had seven counselors who were assigned to provide treatment to the patients. The facility failed to maintain one FTE counselor for every thirty-five active patients.
Employee #2 has a caseload of 37/1.
Employee #3 has a caseload of 37/1.
Employee #4 has a caseload of 37/1.
Employee #5 has a caseload of 38/1.
Employee #6 has a caseload of 38/1.
Employee #7 has a caseload of 38/1.
Employee #8 has a caseload of 36/1.
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Plan of Correction
To hire and train new staff to replace staff that left to bring ratios back into compliance. Once staff is able to be assigned a caseload compliance will be obtained. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of the patient records, the facility failed to document the signature of the medical director on the annual evaluation in four of the six records reviewed.
The findings include:
Twelve patient records were reviewed on August 24-25, 2010. Six of the twelve patient records are required to include an annual evaluation. Four of the six records failed to include the medical director's signature on the annual evaluation.
Patient record # 5 was admitted to treatment on August 13, 2009. The annual evaluation was completed on August 16, 2010. The evaluation was signed by the narcotic treatment physician, but was not signed by the medical director as required.
Patient record # 6 was admitted to treatment on June 24, 2009. The annual evaluation was completed on June 29, 2010. The evaluation was signed by the narcotic treatment physician, but was not signed by the medical director as required.
Patient record # 10 was admitted to treatment on September 4, 2008 and was discharged on March 8, 2010. The annual evaluation was completed on September 11, 2009. The evaluation was signed by the narcotic treatment physician, but was not signed by the medical director as required.
Patient record # 11 was admitted to treatment on March 25, 2009 and was discharged on April 22, 2010. The annual evaluation was completed on March 17, 2010. The evaluation was signed by the narcotic treatment physician, but was not signed by the medical director as required.
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Plan of Correction
The facility director will meet with staff to inform them of the regulation and direct staff to ensure that the medical director is the only physician who is able to sign the annual review. The facility director will also meet with all attending physicians and inform them that only the medical director is able to complete the annual evalutation. To ensure continued compliance random audits will be completed and further instuction will be provided as necessary. |