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 January 15, 16 and 17, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Dolminis was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on February 14, 2008.
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Plan of Correction
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715.9(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
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Observations
Based on random review of 11 patient records, the facility failed to, with patient consent, contact the previous narcotic treatment facility for the treatment history of patient # 11.
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Plan of Correction
Client refused to sign a release for previous NTP. A release will be filed in clients chart with documentation stating that client refused to sign.
Four to five Charts are pulled randomly every month for monitoring by the director and a chart monitoring workgroup has been established by staff to ensure compliance. |
715.16(a)(5) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(5) A narcotic treatment program shall develop written policies and procedures relating to granting and rescinding take-home medication privileges.
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Observations
The facility failed to develop policies and procedures for the rescinding of take-home privileges.
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Plan of Correction
A policy and procedure for rescinding of take-home privileges has been developed and implemented. |
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
The facility failed to provide the minimum amount of counseling required for 10 randomly selected patient records. During the four month period of September 2007 to December 2007, the 10 patients averaged 3.7 hours total for the four months. Only one patient received 6.75 hours total and the remaining patients all received less than 6.5 hours of psychotherapy.
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Plan of Correction
Facility Director addressed issue with staff regarding counseling hours and the need to engage client's in treatment and increase individual and group counseling hours. Client's will be seen according to their needs but not less than the state requirements. If needed a motivational incentive program will be designed and implemented in an attempt to capture clients who are not attending.
This initiative will be monitored monthly by the director and the chart monitoring workgroup. |
715.21 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.
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Observations
Based on random review of patient records, the facility failed to ensure all efforts had been initiated to retain the patient prior to the involuntary termination. Patient # 2, 4, 9, and 11 were involuntarily terminated. The patient records failed to document the efforts the facility had initiated to retain these patients. Patients 2, 4,and 11 were in treatment for 4, 4, and 3 months respectively. The brevity of this time period does not allow for clinical interventions to engage the patient in treatment.
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Plan of Correction
The program will initiate efforts to engage and retain clients in treatment. Also, client records will show specific documentation of the efforts initiated by the program to engage and retain clients.
Staff has been educated on and given examples of methods of engaging clients in treatment as well as documentating their attempts.
Involuntary terminations will be monitored by the medical director and the program director. |
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
A random review of 4 patient records of patients who were involuntarily terminated from treatment substantiated that the facility failed to restrict involuntary terminations of patients from treatment to those conditions permitted by regulation. Patient #2 was discharged for continued used of illicit drugs, patient #4 was terminated for continued use of benzodiazepines. Patient # 9 was terminated for missing counseling appointments; the record lacked documentation of any attempts to engage this patient in treatment. Patient # 11 requested a transfer to another narcotic treatment program which was not done. Instead, the patient record indicates that the patient was discharged while in a psychiatric inpatient hospital unit.
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Plan of Correction
All involuntary terminations will be monitored by the medical director and the program director to help ensure reason(s) for termination has met involuntary termination criteria. The program will initiate efforts to engage and retain clients in treatment. Also, client records will show specific documentation of the efforts initiated by the program to engage and retain clients.
Involuntary terminations will be monitored by the medical director and the program director.
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715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on a review of patient records on January 15, 16 and 17, 2008, it was determined that the facility failed to ensure that the psychosocial evaluation contained a clinical analysis of the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, patient's attitude toward treatment and overall impressions. A review of 10 of 11 patient records, specifically #1, 2, 3, 5, 6, 7, 8, 9, 10, and 11, indicated that the psychosocial evaluation failed to document the patient's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, patient's attitude toward treatment and overall impressions based on the clinician's analysis of the collected historical information.
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Plan of Correction
Facility Director held a training on psychosocial evaluations regarding counselor's analysis of client through information obtained rather than reiterating client's replies to questions. Director also addressed issue of staff's lack of confidence in their capabilities as a clinician to to document their assessment of the client.
Four to five charts are randomly pulled and monitored monthly by Facility Director. A staff workgroup has been implemented to aide with chart compliancy.
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715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on a review of patient records on January 15, 16, and 17, 2008, it was determined that the facility failed to include the reasons for seeking treatment, services provided and the patient's specific response to treatment for patients # 2, 4, 9, and 11..
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Plan of Correction
Facility Director instructed/educated staff that they need to include documentation in the client's chart to include the client's reason for seeking treatment, services provided and the client's specific response to treatment. Four to five Charts are pulled randomly every month for monitoring by the director and a chart monitoring workgroup has been established by staff to ensure compliance
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715.23(d) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
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Observations
The facility failed to develop treatment plans that contained realistic short and long term goals based on the patient's specific needs. Patient #2, admitted August 23, 2007, did not have a comprehensive treatment plan completed until November 21, 2007. Patient # 11's comprehensive treatment plan dated July 21, 2007 contained a goal relating to the disease of alcoholism. This patient has no history of alcohol abuse.
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Plan of Correction
Clinicians have been educated on developing and implementing treatment goals and objectives specific to the client's needs. They have also been educated on the need to keep these goals and objectives to a relatively short time frame to help keep the client engaged and focused. Clinicians have been reminded of the policy and procedure time frame for comprehensive treatment plans.
Four to five charts are randomly pulled and monitored monthly by Facility Director. A staff workgroup has been implemented to aide with chart compliancy.
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715.23(d)(1) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(1) The treatment plan shall identify the behavioral tasks a patient shall perform to complete each short-term goal.
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Observations
The facility failed to identify the type and frequency of counseling each patient needed based upon his/her presenting needs. Additionally, the facility failed to identify the support services each patient needed.
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Plan of Correction
Facility Director has re-educated staff on the importance of documenting client support services on the individual treatment and rehabilitation plan. Staff has also been instructued to document the type and frequency of counseling services based on the clients needs. Four to five charts are randomly pulled and monitored monthly by Facility Director. A staff workgroup has been implemented to aide with chart compliancy. |
715.23(d)(2) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Based on a random review of patient records, the facility failed to document the progress or lack of progress in achieving the goal statements from the prior treatment plan in patient records # 1, 2, 3, 5, 8, and 11. The facility failed to update treatment plans at least every 60 days for patient record # 1, 2, 5, 8, and 11.
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Plan of Correction
Clinicians have been instructed to document lack of progress on goals and objectives that are not yet due or refrain from implementing these goals until a later date.
Facility Director addressed issue with staff regarding treatment plans and the need to update the client's progress on goals and/or revise treatment plans at least every 60 days.
Director also noted the regulation requiring that all treatment plans are to be updated at least every 60 days.
Four with client to five Charts are pulled randomly every month for monitoring by the director and a chart monitoring workgroup has been established by staff to ensure compliance.
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