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 November 27, 28, and 29, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pinnacle Treatment Center PA-III, LLC, d/b/a Alliance Medical Services 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 corrections are due on December 26, 2007.
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Plan of Correction
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715.6(e) LICENSURE Physician Staffing
(e) A physician assistant or certified registered nurse practitioner may perform functions of a narcotic treatment physician in a narcotic treatment program if authorized by Federal, State and local laws and regulations, and if these functions are delegated to the physician assistant or certified registered nurse practitioner by the medical director, and records are properly countersigned by the medical director or a narcotic treatment physician. One-third of all required narcotic treatment physician time shall be provided by a narcotic treatment physician. Time provided by a physician assistant or certified registered nurse practitioner may not exceed two-thirds of the required narcotic treatment physician time.
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Observations
The facility failed to maintain the required ratio of one-third physician time to no more than two-thirds physician assistant time at all times. For the weeks ending September 10, 2007 and October 29, 2007, there was 8.5 hours of physician time for 21 hours of physician assistant time. This needed to be 10.5 hours of physician time.
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Plan of Correction
The Medical Director will ensure that the proper ratio will be maintained at all times including holiday weeks, vacation weeks, or conference attendance weeks. He will do this by adjusting his work schedule and/or notifiying the back-up physician for coverage. This will be monitored by the Facility Director. |
715.8(1)(vi) LICENSURE Psychosocial Staffing
A narcotic treatment program shall comply with the following staffing ratios as established in Chapter 704 (relating to staffing requirements for drug and alcohol treatment activities):
(vi) Outpatients. The counseling caseload for one FTE counselor in an outpatient narcotic treatment program may not exceed 35 active patients.
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Observations
The facility failed to maintain this ratio for the clinical supervisor whose ratio was 60:1. The facility's overall patient to counselor ratio is 35:1.
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Plan of Correction
As of December 1, 2007, the Clinical Supervisor has reduced her caseload to five patients. She will not increase her caseload beyond five patients. She will increase her participation in clinical activities involving supervision of counselors. This will be monitored by the Facility Director. |
715.9(e) LICENSURE Intake
(e) A narcotic treatment program shall secure a personal history from the patient within the first week of admission. The personal history shall be made a part of the patient record.
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Observations
The facility failed to obtain a personal history within the first week of admission.
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Plan of Correction
As of December 1, 2007, the intake forms were revised by the Facility Director to include the necessary personal history information. This information is collected prior to a patients admission and first dose. |
715.14(a)(2) 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.
(2) If the narcotic treatment program determines that other drugs are abused in that narcotic treatment program 's locality or have been identified in the patient 's drug and alcohol history as being a drug of abuse or use, a narcotic treatment program may conduct a test or analysis for other drugs as well.
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Observations
The facility failed to test for cannabis when it is known to be an illicit drug frequently used in the local area and identified in patient drug and alcohol histories.
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Plan of Correction
THC testing will continue at admission. If a patient is identified as a THC user at admission and/or through the D/A psycho-social evaluation, THC testing will continue monthly as part of their random drug screen as per the treatment plan and counselor recommendation. All Patients who are eligible for take-home privileges will be tested for THC, in addition to the other regularly tested substances, prior to them being instituted and prior to any increase in privilege level. The THC test will be added on during the regular random monthly screen prior to eligibility. As of January 1, 2007 AMS will be using a new laboratory for monthly screens that ensures a 24 hour turn-around in results from when the specimen is received. The Medical Director, Clinical Supervisor, and counselors will be responsible for monitoring this procedure. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
The facility failed to have the narcotic treatment physician determine the dose for each patient. The physician had issued standing orders for intoxicated and pregnant patients and for patients who requested a dose increase. The standing orders require the nurse to determine the dose the patient would receive. The physician must determine each patient's dose and order the same.
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Plan of Correction
As of 11/29/07, all standing orders were eliminated. All changes in doses are determined by the physician on-site or through verbal order, which is then signed within 24 hours. The Medical Director and Facility Director will be responsible for monitoring on-going 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 procedures for rescinding take-home privileges when a patient no longer meets the 8 point criteria.
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Plan of Correction
The Project Director will be responsible for amending the policy regarding recinding take-home privileges. As of December 1, 2007, the procedure will be to immediately recind all privileges with a positive drug test. Individualized plans for reinstatement will be developed by the counselor, patient, and treatment team. The written policy will reflect this practice. The Clinical Supervisor will be responsible to ensure that this procedure is followed. |
715.21(2) 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.
(2) A patient terminated involuntarily, except a patient who commits or threatens to commit acts of physical violence, shall be afforded the opportunity to receive detoxification of at least 7 days. The detoxification may take place at the facility or the patient may be referred to another narcotic treatment program or hospital licensed and approved by the Department for detoxification.
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Observations
The facility failed to have the physician determine the length of the detoxification based on factors such as the patient's current dose, length of time in treatment and nature of the regulation violation. Instead the facility gave the patient a choice of a 7 day involuntary detoxification or a 10 day voluntary detoxification. It is not a voluntary detoxification when the facility has determined the patient needs to be detoxed. The physician must determine the detox schedule.
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Plan of Correction
As of December 14, 2007, the voluntary and involuntary detoxification forms have been amended to reflect the physician's order for length/course of detoxification. The Clinical Supervisor will be responsible to train the counselors on correct documentation for involuntary detoxifications. The Medical Director will be responsible to ensure that all detoxification orders are specific to each patient. |
715.23(b)(2) LICENSURE Patient records
(b) Each patient file shall include the following information
(2) A complete drug and alcohol history.
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Observations
The facility failed to develop a complete drug and alcohol history for each patient that included the pattern and length of use of each substance.
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Plan of Correction
The Alliance Medical Services Clinical Committee will review the Drug & Alcohol History portion of the assessment tool in order to restructure the section. The emphasis will be on providing a structure by which the history will clearly show a progression of use, abuse, and dependency by life stage. In doing this, lengths, patterns, and life events will be throughly detailed. The revised tool will be in place by Jan 1, 2007. Both the Project Director and Facility Director will be responsible for these revisions. |
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
A random review of patient records revealed that the facility failed to develop a comprehensive evaluation of the data gathered in the histories to access conditions, causes or relationships.
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Plan of Correction
By January 15, 2007, the Clinical Supervisor will conduct in-house training with counselors regarding the proper techniques for completing evaluative summaries. The Clinical Supervisor will be responsible for on-going monitoring through weekly chart reviews. |
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
A random review of patient files revealed that the facility failed to develop long term goals for each patient.
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Plan of Correction
By January 15, 2007, The Clinical Supervisor will conduct in-house training with counselors on development of long-term goals for patients as well as distinguishing between and documenting long and short term goals. The Clinical Supervisor will be responsible for on-going monitoring of treatment plans through weekly chart reviews. |