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 September 16-18, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center for Behavioral Health- PA, 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.
Deficiencies were identified during this inspection and plan of correction is due on October 17, 2009.
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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 facility failed to document dosage reviews that were consistent with th regulations in three of seven patient records.
The findings include:
Sixteen patient records were reviewed on September 16-18, 2009. Seven were reviewed for documentation that identified that the physician had conducted dosage reviews at least twice a year. Three patient records failed to include documentation of the physician's review of patient dosage. Patient records # 8, 9, and 11 included documentation that the CRNP had reviewed the patient dosages and determined them to be therapeutic. Only the physician may make these determinations.
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Plan of Correction
Medical Director had reviewed and signed patient charts #8, #9, and #11 to determine if dose was therapeutic.
CRNPs have been notified by Program Director of PA Dept. of Regulations and Discovery House Policy regarding dose reviews. CRNPs will only gather information for Medical Director's review and not complete dose reviews.
Medical Director will review dose levels for therapeutic range at least twice a year and within two months apart. Program Director will audit dose reviews to ensure that Medical Director is the only person determining the patient's dose to be therapeutic. |
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, the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment in one of five patient records.
The findings included:
Sixteen patient records were reviewed on September 16-18, 2009. Five were reviewed for psychotherapy content and compliance with the regulation. In patient record # 8, the patient received 2.5 hours of psychotherapy in June 2009, 1.25 hours of psychotherapy in July, 2009 and 2.50 hours of psychotherapy in August, 2009 for an average of 2.08 hours of psychotherapy.
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Plan of Correction
Patient #8 has been offered and will complete an extra counseling session consisting of 1.25 hours this month.
Clinical supervisor will pull the "Direct Service Hours" report for each counselor and review in supervision. Each month's report will be compared to ensure that patients are meeting the required counseling hours. If for any reason a patient did not obtain the required counseling hours, clinical supervisor will ensure that the primary counselor has offered extra counseling the following month.
Program Director will complete spot checks and compare "Direct Service Hours" report to ensure all patients are obtaining the required amount of counseling appropriate to their level of care. |
715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. 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, the facility failed to provide each patient with at least one hour of hours of psychotherapy per month during the third and fourth year of treatment, in one of one of two patient records.
The findings included:
Sixteen patient records were reviewed on September 16-18, 2009. Two were reviewed for the psychotherapy requirement of at least one hour per month. There was no documentation in patient record # 7 that showed the patient received the required psychotherapy hours.
Patient # 7 was admitted as a transfer patient on July 13, 2009, the patient received .50 hours of psychotherapy in July 2009 and 0 hours of psychotherapy in August, 2009.
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Plan of Correction
Clinical supervisor will pull the "Direct Service Hours" report for each counselor and review in supervision. Each month's report will be compared to ensure that patients are meeting the required counseling hours. If for any reason a patient did not obtain the required counseling hours, clinical supervisor will ensure that the primary counselor has offered extra counseling the following month to prevent counseling deficiencies.
Program Director will complete spot checks and compare "Direct Service Hours" report to ensure all patients are obtaining the required amount of counseling appropriate to their level of care.
Upon further review of patient chart #7, it was found that patient had the required amount of counseling since admission. Program Director will be better organized to provide licensing specialists with documentation of all clinical services in future surveys. |
715.21(1)(i-iv) 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.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
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Observations
Based on a review of patient records, the facility failed to provide written notice of an involuntary termination in one of one patient record where required.
Finding:
Sixteen client records were reviewed on September 16-19, 2009. One patient record was reviewed for documentation of written notice of an involuntary termination. There was no documentation in patient record # 4 that the patient had been notified, in writing, of an involuntary termination.
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Plan of Correction
Program Director had obtained clarification and has instructed treatment team that any instance of involuntary termination (including this case where patient committed act of violence and threatened safety of himself and others therefore terminated instantly) will be given written notice, even if it is mailed to patient's residence.
Since all involuntary terminations need to be approved by Director before action is taken, Program Director will be responsible to insure that documentation is in place and patient is notified. |