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 December 14 - 16, 2009 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 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 January 5, 2010. .
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Plan of Correction
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Observations
Based on the review of time sheets, census reports and an interview with the facility director, the facility failed to provide at least one hour of physician time per week on site for every ten patients.The findings include:On December 14 - 15, 2009, census reports and physician time sheets were reviewed for the months of August, September, October, November and December. There were insufficient onsite physician hours in October.During the week of October 4 - 10, 2009, the census was 227 patients and 3 physician hours.During the week of October 11 - 17, 2009, the census was 227 patients and 3 physician hours.The facility director was interviewed at approximately 1:00 PM on December 15, 2009. The facility director confirmed there were insufficient physician hours from October 4 through October 17, 2009; due to the previous medical director being on vacation. The back up physician was only available to work a total of 6 hours during this time period.
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Plan of Correction
The back up physician will work the required 1 hour per every 10 clients when covering for the medical director beginning immediately.
Physician hours will be monitored closely by the director of nursing and the program director. |
Observations
Based on a review of patient records and an interview with the facility director, the facility failed to document an annual evaluation by the counselor that included the patient's legal standing, financial management abilities and physical and emotional health in six of six patient records, as required per regulation.The findings include:On December 14 - 16, 2009, twenty patient records were reviewed. Of these patient records, six patient records contained documentation that identified they had been in treatment for more than a year and required the completion of an annual evaluation. The facility failed to document an annual evaluation that included the patient's legal standing, financial management abilities and physical and emotional health in patient records # 6, 7, 15, 16, 17 and 18.Patient # 6 was admitted to the program on May 1, 2007. The annual evaluation for 2009 was completed on May 19, 2009. The annual evaluation did not include the patient's legal standing, financial management abilities and physical and emotional health.Patient # 7 was admitted to the program on February 22, 2007. The annual evaluation for 2009 was completed on March 10, 2009. The annual evaluation did not include the patient's legal standing, financial management abilities and physical and emotional health.Patient # 15 was admitted to the program on November 20, 2008. The annual evaluation for 2009 was completed on December 9, 2009. The annual evaluation did not include the patient's legal standing, financial management abilities and physical and emotional health.Patient # 16 was admitted to the program on September 17, 2008. The annual evaluation for 2009 was completed on September 16, 2009. The annual evaluation did not include the patient's legal standing, financial management abilities and physical and emotional health.Patient # 17 was admitted to the program on September 9, 2008. The annual evaluation for 2009 was completed on August 26, 2009. The annual evaluation did not include the patient's legal standing, financial management abilities and physical and emotional health.Patient # 18 was admitted to the program on April 17, 2007. The annual evaluation for 2009 was completed on April 8, 2009. The annual evaluation did not include the patient's legal standing, financial management abilities and physical and emotional health.On October 16, 2009, at approximately 1:00 PM, the facility director was interviewed. The facility director reviewed the form utilized for annual evaluations by the counselor and confirmed the form does not include the patient's legal standing, financial management abilities or physical and emotional health. The facility director reported the annual evaluation form will be reviewed and revised to include all items required by regulation.
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Plan of Correction
The annual evaluation form will be reviewed at the next operational program meeting scheduled for 1/19/09. Management will look at revising the form to include patient's legal standing, financial management abilities and physical and emotional health status.
The form will be implemented no later than 2/1/09.
The annual evaluation documentation will be monitored by the clinical supervisor and/or the program director during monthly chart reviews. |