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 May 21-22, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northeast Family Health Care, LLC 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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715.19(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 counseling services as stated on the treatment plan or an average of 2.5 hours of psychotherapy per month in four of five patient records.
The findings include:
Nine patient records were reviewed May 21-22, 2013. Counseling services were reviewed for provision according to the treatment plan and an average of 2.5 hours of psychotherapy per month in five patient records.
Patient # 2 was admitted January 23, 2013. The comprehensive treatment included type and frequency that was pre-printed to be provided on a weekly basis. The last documented counseling session was dated more then a month prior to the inspection, April 9, 2013. There was no documentation of why the services were not being provided.
Patient # 4 was admitted April 5, 2013. The treatment plan stated the patient was to attend a weekly individual session and a weekly group session. The last documented session was dated April 17, 2013. There was no documentation of why the services were not being provided.
Patient # 6 was admitted November 13, 2012. The comprehensive treatment included type and frequency that was pre-printed to be provided on a weekly basis. The patient received two hours of counseling services in January 2013, less then two and one half hours of counseling services in February 2013 and less than two hours of counseling services in March. During the four months reviewed, February, March, April and May, the patient received 1.75 hours average of counseling services.
Patient # 7 was admitted November 7, 2012. The comprehensive treatment included type and frequency that was pre-printed to be provided on a weekly basis. The patient had no documented counseling services in April 2013 and none in May 2013 at the time of the inspection. During the final three months of treatment, the patient received an average of 2.12 hours of counseling per month.
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Plan of Correction
The counselors have been instructed in the use of dose holds as well as on documentation and counseling frequency expectations. This took place during the week of June 3 through June 8, 2013. This supervision included the expectation that rescheduled, cancelled and no-show counseling appointments be documented in the case record. Counselors were instructed in the use of treatment contracts for counseling attendance.
The Facility Director will randomly review 20% of each counselor's caseload each month for six months to ensure compliance with counseling frequency expectations. |
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 review of patient records and administrative documentation, the facility failed to ensure all efforts had been initiated to retain the patient prior to the involuntary termination and restricting the reasons to those listed.
The Findings Include:
Nine patient records were reviewed May 21-22, 2013. The patient handbook was reviewed May 21, 2013.
The patient handbook that is provided to patients upon admission to the facility stated the patients were at risk for immediate discharge for carrying weapons or illegal substances onto the grounds of the facility. The possession of illegal substances is not grounds for immediate discharge as specified by regulation.
Patient # 8 was admitted October 3, 2012 and involuntarily discharged for financial purposes February 1, 2013. Patient termination for financial reason is not grounds for immediate discharge as specified by regulation.
Patient # 9 was admitted October 11, 2012 and discharged for financial purposes January 29, 2013. Patient termination for financial reason is not grounds for immediate discharge as specified by regulation.
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Plan of Correction
The Program Director will implement an assessment tool for self-pay clients designed to help us determine:(a)patients ability to pay, (b) barriers to payment, and (c)willingness to pay.
All clinical staff will be trained on how to address non-payment, to include documentation of reasons for non-payment and intervention efforts. Treatment compliance plans will be used in situations of non-payment when the patient has been determined to have the means to pay, however are simply unwilling to do so. Only in those cases would we initiate discharge. A staff training has been conducted to instruct all staff on assessing, documenting, and addressing situations of non-payment.
The facility will ensure that discharge recommendations are compliant with 715.21 by adding language to treatment plans that clearly identifies the need to maintain compliance the individual patient's action steps and goals. This will ensure that discharges are always in compliance with treatment plan compliance as required by 715.21
Ongoing compliance will be monitored by the Facility Director and/or Project Director through random chart audits.
Additionally, all discharges must be approved in advance by the Facility Director or Project Director for the next six months. |
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, the facility failed to complete all required laboratory tests as part of the admission process in six of seven patient records reviewed.
The findings include:
Nine patient records were reviewed May 21-22, 2013. Seven patient records were reviewed for completed laboratory tests as part of the admission process, specifically a completed blood serology tests for Syphilis.
Patient records # 2, 3, 4, 5, 6 and 7 did not have documentation of a completed blood serology test for Syphilis having been administered as part of the admission process required.
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Plan of Correction
The nursing staff has been instructed to make a minimum of two attempts to obtain the blood serology test for syphilis for all new patients. If after two attempts the nurse is unable to complete the test, the patient will be sent to an outside laboratory with which the facility has an agreement for laboratory testing. This testing shall be completed within three weeks of admission.
The Facility Director and the Medical Director will review all charts for patients admitted after June 1, 2013 for compliance. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on the review of patient records, the facility failed to ensure follow up for two of three patients reviewed.
The findings include:
Nine patient records were reviewed May 21-22, 2013. Three patient records required documentation of a follow up attempt.
Patient # 7 was admitted November 7, 2012 and discharged March 28, 2013 as a transfer to another facility. There was no documentation the facility attempted to make a follow up contact. There was a signed consent by the patient for the receiving facility.
Patient # 8 was admitted October 3, 2012 and discharged February 1, 2013. The patient was involuntarily discharged February 1, 2013. There was no documentation at the time of the inspection of any follow up attempt. There was documentation through a signed consent to release information indicating the patient may have been transferred, but this was never clarified within the record reviewed. Some attempt was to have been made within a week of the referral completion.
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Plan of Correction
The counselors have been instructed in the policy on follow up expectation. This took place in individual supervision during the week of June 3 through June 7, 2013. The use of the standard follow up form was reviewed. Counselors were instructed that follow ups must be completed for all discharged patients beginning June 1, 2013.
The Facility Director will randomly review 20% of each counselor's caseload each month for six months to ensure compliance with follow up expectations. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on review of administrative documentation provided during the inspection, the facility failed to submit documentation of unusual incidents to the Department within 48 hours as required.
The findings include:
Administrative documentation that included unusual incident reports was reviewed May 21, 2013.
April 11, 2013 a report stated that a patient pulled out of the parking lot after dosing and hit a motorcycle. This was an incident with the potential for negative community reaction. This was not reported to the Department.
April 12, 2013 police were called onsite. This was not reported to the Department.
April 14, 2013, during hours the facility was closed, the alarm system was triggered and police came onsite. When the facility director arrived, it was reported that the police were able to enter into the unsecured rear door. This was an incident with the potential for negative community reaction. This was not reported to the Department.
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Plan of Correction
The Facility Director reviewed the regulation on Unusual Incidents with the Project Director on June 6, 2013. The Facility Director will be responsible for ensuring that the regulation is followed beginning on June 10, 2013. The Project Director will review the Unusual Incidents binder kept in the Facility Director's office at least twice monthly to ensure that the regulation is being followed. |