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 October 3 - 4, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Progressive Medical Specialists, 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.
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Plan of Correction
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715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, the facility failed to document a random urinalysis at least monthly in two of twelve patient records.
The findings include:
The monthly urine screen results for twelve patients were reviewed on October 3-4, 2013. All twelve patients were required to complete random monthly urinalysis. Patient records # 6 and # 8 did not include documentation of monthly urine screen results.
Patient #6 was admitted to treatment on May 31, 2013 and was discharged on August 5, 2013. There was no documentation of a urinalysis for June 2013.
Patient #8 was admitted to treatment on May 4, 2012. There was no documentation of a urinalysis for July 2013.
The findings were reviewed with the facility director and were not disputed.
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Plan of Correction
Upon review of charts inspected at the time of this visit and discussion with state inspector regarding the missed urine samples by these two patients, project director instructed medical and clinical staff to review active patient charts to ensure that there were no other patients that this happened too. This review of charts was completed by October 11, 2013 and we did not have any other patient missing a monthly urine result report.
Director met with medical staff on October 4, 2013 and reviewed our current urine collection process. We do not believe our process needs changed at this time but we believe that an end of the day check will need to be completed a little differently due to the facility using a new urine testing company. This revised end of the day check will begin on October 7, 2013.
During the meeting with medical staff, it was brought up that we changed to a new urine company in the middle of June and possibly due to this change we some how missed collecting a urine sample from these two patients. We are not sure that this change had anything to do with missing two patient's monthly urine samples but it may have been a factor since this has never been an issue for us in the past and the only change in our current process has been using this new company.
The nursing staff will continue to use our current process to collect urine samples from patients but at the end of the day nursing staff will repack the pick up box and check the samples collected with the computer generated daily report of patients that were required to give a sample to ensure that all samples were all obtained.
Our computer program is designed to identify patients on a daily basis that ensures a sample is collected monthly for each active patient in treatment.
Also, director requested that clinical staff notify nursing staff prior to the end of each month if they notice they did not receive a test result report for one of their patients. This will allow nursing staff time to investigate and obtain a sample for the patient if needed.
Director believes that with the clinical staff receiving copies of urine reports, the monthly tracking sheet of a patient's urine test results that are filed in each clinical chart, the number of chart reviews completed and our current urine collection process we can ensure that all patients provide a monthly random urine sample for testing.
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715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on a review of patient records, the facility failed to ensure that the initial medication order was written and signed by the narcotic treatment physician in seven of seven patient records.
The findings include:
Twelve patient records were reviewed on October 3 -4, 2013. Seven patient records were reviewed for the initial medication order which shall be written and signed by the narcotic treatment physician. Patient records # 3, 4, 6, 9, 10, 11, and 12 documented initial medication orders that were completed by someone other than the narcotic treatment physician.
Patient #3 was admitted to treatment on 12-14-2012 and was discharged on 6-3-2013. The initial medication order was written on 12-13-2013 by someone other than the narcotic treatment physician.
Patient #4 was admitted to treatment on 5-22-2013 and was discharged on 8-7-2013. The initial medication order was written on 5-21-2013 by someone other than the narcotic treatment physician.
Patient #6 was admitted to treatment on 5-31-2013 and was discharged on 8-5-2013. The initial medication order was written on 5-30-2013 by someone other than the narcotic treatment physician.
Patient #9 was admitted to treatment on 7-26-2013. The initial medication order was written on 7-26-2013 by someone other than the narcotic treatment physician.
Patient #10 was admitted to treatment on 8-3-2013. The initial medication order was written on 8-1-2013 by someone other than the narcotic treatment physician.
Patient #11 was admitted to treatment on 8-16-2013. The initial medication order was written on 8-15-2013 by someone other than the narcotic treatment physician.
Patient #12 was admitted to treatment on 3-29-2013 and was discharged on 9-5-2013. The initial medication order was written on 3-28-2013 by someone other than the narcotic treatment physician.
The findings were reviewed with the facility director and the nurse and were not disputed.
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Plan of Correction
Director met with medical director and discussed findings from inspection on October 4, 2013 and October 9, 2013.
Medical charts that we reviewed at our inspection were reviewed by MD, Project director and nurse supervisor on October 9, 2013 and it is understood by MD what he is required to complete in regards to documents.
Medical director and project director spoke to dispensing staff, nurse supervisor and PA on October 9, 2013 and discussed inspection results as well as medical activity that only the/a MD can perform.
MD will be the only staff member that will complete any new admission physicals/paperwork which should prevent this from occurring again.
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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 a 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 two years of treatment in three of ten records.
The findings include:
Twelve patient records were reviewed on October 3 -4, 2013. Ten patient records were reviewed for 2.5 hours of psychotherapy hours during the first two years of treatment. Patient records # 7, 8, and 9 did not have the average 2.5 hours of therapy.
Patient #7 was admitted to treatment on 9-7-2012. The facility failed to provide 2.5 hours of psychotherapy hours for August 2013.
Patient #8 was admitted to treatment on 5-4-2012. The facility failed to provide 2.5 hours of psychotherapy hours for September 2013.
Patient #9 was admitted to treatment on 7-26-2013. The facility failed to provide 2.5 hours of psychotherapy hours for August 2013.
The findings were reviewed with the facility director and were not disputed.
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Plan of Correction
Director met with clinical supervisor on October 4, 2013 and clinical staff on October 9, 2013 to discuss required counseling hours as per regulations.
On October 11, 2013 the three clients identified during the inspection had their clinical chart reviewed by director, clinical supervisor and lead counselor. Two of these clients had already had a plan in place for additional counseling to be held in October and a case consultation was completed and a plan was developed for the primary counselor to meet with the third client for an extra session in October.
We do understand that regulations require 2.5 hours of counseling for clients in their first two years of treatment but when we have identified clients that have not obtained required counseling time in a month we have always added session time with that individual client.
Due to the design of a monthly tracking report completed by each counselor and turned into the clinical supervisor and director by the 5th of every month we are able to clearly identify any client that did not receive required counseling time for that month. As a result, we are able to address missed counseling easily and quickly with the staff member and the client.
The director and clinical supervisor will continue to review this report to identify any client that did not receive required counseling time each month.
The director and/or clinical supervisor will meet with any counselor who did not obtain required time for each client on their caseload.
The counselor and supervisor will discuss any concerns/issues that may be preventing him/her from meeting required counseling time with a client.
If it is a staffing issue that is causing counseling time to not be met, the counselor's monthly individual training plan will address the issue (s).
If required counseling time is not being met due to a client issue, a case consultation will be completed with the primary counselor, clinical supervisor and/or director that will have a plan to address the missed sessions and any other treatment issues that could be interfering with client's ability to meet counseling requirement. Based upon the review of the client's treatment the plan could include the use of our disciplinary process.
We have had a significant change in our clinical staff the last year that may have affected these three clients from obtaining required counseling hours.
Although there is a plan in place that ensures clients are seen by a counselor as per regulations when we have a staff change or an open clinical position a client's counseling time could have been effected by the change in our clinical staff.
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