INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use of narcotic agents, specifically methadone and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on September 2-3, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, WPIC Narcotic Addiction Treatment Program 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 October 4, 2010.
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Plan of Correction
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715.16(b)(1-8) LICENSURE Take-home privileges
(b) The narcotic treatment physician shall consider the following in determining whether, in exercising reasonable clinical judgment, a patient is responsible in handling narcotic drugs:
(1) Absence of recent abuse of drugs (narcotic or non-narcotic), including alcohol.
(2) Regular narcotic treatment program attendance.
(3) Absence of serious behavioral problems at the narcotic treatment program.
(4) Absence of known recent criminal activity.
(5) Stability of the patient 's home environment and social relationships.
(6) Length of time in comprehensive maintenance treatment.
(7) Assurance that take-home medication can be safely stored within the patient 's home.
(8) Whether the rehabilitative benefit to the patient derived from decreasing the frequency of attendance outweighs the potential risks of drug diversion.
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Observations
Based on a review of patient records and staff interviews, the facility failed to consider the criteria for take-home privileges in one of two patient records.
The findings include:
Eighteen patient records were reviewed on September 2-3, 2010. Two patient records were reviewed for compliance with the regulations regarding take-home medications. Per regulation, the narcotic treatment physician shall consider the following in exercising reasonable clinical judgment, a patient is responsible in handling narcotic drugs: absence of recent abuse of drugs (narcotic or non-narcotic), including alcohol, regular narcotic treatment program attendance, absence of serious behavioral problems at the narcotic treatment program, absence of known recent criminal activity, stability of the patient 's home environment and social relationships, length of time in comprehensive maintenance treatment. assurance that take-home medication can be safely stored within the patient 's home, and whether the rehabilitative benefit to the patient derived from decreasing the frequency of attendance outweighs the potential risks of drug diversion. The facility failed to consider the criteria for take-home privileges in patient record # 1.
Patient # 1 was admitted into treatment on May 13, 2010. Patient # 1 transferred into treatment from another narcotic treatment program and was immediately granted take-home privileges. There was no documentation that the criteria had been considered for take-home privileges prior to the take home privileges being granted in patient record # 1.
The clinical supervisor was interviewed on September 2, 2010. He reviewed patient record #1 and confirmed that there was no documentation that the criteria had been considered prior to granting take-home privileges.
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Plan of Correction
The Medical Director will ensure that there is documentation that the criteria for take-home privileges has been considered prior to the take home privileges being granted. A form: Physician's Documentation of Addiction will be completed at intake and will verify the documentation has been completed. Monitoring of the use of the form will be completed by the nurse coordinator through ongoing quality assurance chart audits. Implementation of the form will occur before 10/1/2010. |
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 the review of patient records and an interview with the clinical supervisor, the facility failed to provide 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 in one of three patient records.
The findings include:
Eighteen patient records were reviewed on September 2-3, 2010. Eight patient records were reviewed for the completion of an average of 2.5 psychotherapy hours per month, 1 hour of which shall be individual psychotherapy. 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, 1 hour of which shall be individual psychotherapy in patient record # 2.
Patient # 2 was admitted on May 24, 2010. The patient received an average of 3.83 hours of group psychotherapy services in July 2010. There were no individual psychotherapy hours documented for the month of July, 2010.
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Plan of Correction
The Clinical Supervisor will conduct an in-service training, to include all clinical staff, to review the requirements of providing individualized psychotherapy services. Clinical Supervisor will continue to enforce requirement during supervision sessions. The in-service will occur before October 1, 2010. |
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 the review of patient records, the facility failed to complete annual evaluations in accordance with the regulations in four of four patient records reviewed.
The findings included:
Eighteen patient records were reviewed on September 2-3, 2010. Four patient records were reviewed for completion of an annual evaluation of each patient's status. Per regulation, 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: Employment, education and training, legal standing, substance abuse, financial management abilities, physical and emotional health, fulfillment of treatment objectives and family and community supports. The facility did not document that an annual evaluation was completed per regulation in patient records # 6, 7, 8 and 9.
Patient #6 was admitted on April 30, 2008. An annual evaluation was to be completed by April 30, 2010. The annual evaluation was completed by the counselor on August 20, 2010 and signed by the medical director on September 2, 2010.
Patient # 7 was admitted on April 8, 2009. An annual evaluation was to be completed by April 8, 2010. The annual evaluation was completed by the counselor and signed by the medical director on August 31, 2010.
Patient # 8 was admitted on June 16, 2009. An annual evaluation was to be completed by June 16, 2010. The annual evaluation was completed by the counselor and signed by the medical director on July 16, 2010.
Patient # 9 was admitted on February 7, 2008. An annual evaluation was to be completed by February 7, 2010. The annual evaluation was completed by the counselor and signed by the medical director on June 9, 2010.
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Plan of Correction
Through quality assurance chart reviews, the Clinical Supervisor will ensure the completion of annual evaluations completed by the patient 's counselor and reviewed, dated and signed by the medical director, that address employment, education and training, legal standing, substance abuse, financial management abilities, physical and emotional health, fulfillment of treatment objectives and family and community supports and are in accordance with the regulations. Counselor's will be reminded of the necessity of timely completion of annual evaluations by October 1, 2010. |