INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 20, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center for Addictive Disease - Main Line Affiliates was found not to be in compliance with the applicable chapters of 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 a review of patient records, the facility failed to document 1 hour of individual psychotherapy per month in six of six patient records reviewed. The findings include:On September 20, 2013, six patient records requiring documentation of 1 hour of individual psychotherapy per month were reviewed. The facility did not document 1 hour of individual psychotherapy per month in six of six records reviewed, specifically, patient records # 1, 2, 4, 5, 6, and 7. Patient # 1, a suboxone patient, was admitted February 6, 2013 and prescribed suboxone on February 26, 2013. The facility was required to provide 1 hour of individual psychotherapy per month after the patient was prescribed suboxone on February 26, 2013. However, patient record # 1 did not include documentation of individual psychotherapy as of September 20, 2013.Patient # 2, a suboxone patient, was admitted May 22, 2013 and prescribed suboxone on June 13, 2013. The facility was required to provide 1 hour of individual psychotherapy per month after the patient was prescribed suboxone on June 13, 2013. However, patient record # 2 did not include documentation of individual psychotherapy as of September 20, 2013.Patient # 4, a suboxone patient, was admitted June 5, 2013 and prescribed suboxone on June 27, 2013. The facility was required to provide 1 hour of individual psychotherapy per month after the patient was prescribed suboxone on June 27, 2013. However, patient record # 4 did not include documentation of individual psychotherapy as of September 20, 2013.Patient # 5, a suboxone patient, was admitted March 21, 2013 and prescribed suboxone on April 9, 2013. The facility was required to provide 1 hour of individual psychotherapy per month after the patient was prescribed suboxone on April 9, 2013. However, patient record # 5 did not include documentation of individual psychotherapy as of September 20, 2013. Patient # 6, a suboxone patient, was admitted April 18, 2013 and prescribed suboxone on May 2, 2013. The facility was required to provide 1 hour of individual psychotherapy per month after the patient was prescribed suboxone on May 2, 2013. However, patient record # 6 did not include documentation of individual psychotherapy as of September 20, 2013. Patient # 7, a suboxone patient, was admitted February 11, 2013 and prescribed suboxone on March 7, 2013. The facility was required to provide 1 hour of individual psychotherapy per month after the patient was prescribed suboxone on May 7, 2013. However, patient record # 7 did not include documentation of individual psychotherapy as of September 20, 2013. The findings were confirmed during an interview with the facility director on September 20, 2013 at approximately 4:00 P.M.
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Plan of Correction
Patients 1,2,4,5,6 and 7 will attend individual appointments the week of November 4th. Patients 1,2,4,5,6,and 7 will be assigned to an individual therapist by their program therapist the week of October 28th. A program will be developed by the clinical supervisor with specific plans for clients to work on issues related to their suboxone use. The individual appointments of clients 1,2,4,5,6, and 7 and the sessions for all other suboxone individual sessions will be documented in the chart by the individual therapist who conducts the session. This documentation will be audited monthly by the auditor. Every other suboxone client will be assigned an appointment the week of November 4th that they will attend during the month of November and each month after that by their program therapist. Each new client will be assigned an individual appointment by the suboxone coordinator at the time of their signing of the contract for the program. Moving forward the clinical supervisor will be responsible for making sure all existing and new suboxone clients during the first two years will receive at least one hour of individual psychotherapy per month. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on a review of the facility's census for active suboxone patients on September 20, 2013, the facility failed to notify the Department within 90 days of the occurrence of a change in the authorized maximum capacity of suboxone patients.The findings include:On September 20, 2013, the Licensing Specialist reviewed the facility's census for active suboxone patients. The facility's authorized maximum capacity for suboxone patients is 30. However, based on the facility's census for active suboxone patients, the total number of active suboxone patients in the facility was 45. The facility exceeded their authorized maximum capacity for the Outpatient Other Chemotherapy licensed activity by 15 patients. The findings were confirmed during an interview with the facility director on September 20, 2013 at approximately 4:00 P.M.
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Plan of Correction
A letter has been written and sent by the Project Director to the Department of Drug and Alcohol Programs to request an increase in the patient capacity for the Outpatient Other Chemotherapy Program by October 22, 2013. If the department does not approve the increase of the facility's suboxone patient capacity the facility will properly refer all clients over the allowed capacity to other facilities or suboxone doctors and they will be discharged from the suboxone program, this will be done by their program therapists. |
711.91(b)(5) LICENSURE Physical Examination
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Based on a review of patient records, the facility failed to document a physical examination in seven of seven patient records reviewed. The findings include:On September 19, 2013, seven patient records requiring documentation of a physical examination were reviewed. The facility did not document a physical examination in seven of seven records reviewed, specifically, patient records # 1, 2, 4, 5, 6, 7, and 8. Patient # 1, a suboxone patient, was admitted February 6, 2013 and prescribed suboxone on February 26, 2013. A physical examination was due prior to the patient being prescribed suboxone on February 26, 2013. However, patient record # 1 did not include documentation of a physical examination as of September 20, 2013.Patient # 2, a suboxone patient, was admitted May 22, 2013 and prescribed suboxone on June 13, 2013. A physical examination was due prior to the patient being prescribed suboxone on June 13, 2013. However, patient record # 2 did not include documentation of a physical examination as of September 20, 2013.Patient # 4, a suboxone patient, was admitted June 5, 2013 and prescribed suboxone on June 27, 2013. A physical examination was due prior to the patient being prescribed suboxone on June 27, 2013. However, patient record # 4 did not include documentation of a physical examination as of September 20, 2013.Patient # 5, a suboxone patient, was admitted March 21, 2013 and prescribed suboxone on April 9, 2013. A physical examination was due prior to the patient being prescribed suboxone on April 9, 2013. However, patient record # 5 did not include documentation of a physical examination as of September 20, 2013.Patient # 6, a suboxone patient, was admitted April 18, 2013 and prescribed suboxone on May 2, 2013. A physical examination was due prior to the patient being prescribed suboxone on May 2, 2013. However, patient record # 6 did not include documentation of a physical examination as of September 20, 2013.Patient # 7, a suboxone patient, was admitted February 11, 2013 and prescribed suboxone on March 7, 2013. A physical examination was due prior to the patient being prescribed suboxone on March 7, 2013. However, patient record # 7 did not include documentation of a physical examination as of September 20, 2013.Patient # 8, a suboxone patient, was admitted September 6, 2013 and prescribed suboxone on September 6, 2013. A physical examination was due prior to the patient being prescribed suboxone on September 6, 2013. However, patient record # 8 did not include documentation of a physical examination as of September 20, 2013. The findings were confirmed during an interview with the facility director on September 20, 2013 at approximately 4:00 P.M.
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Plan of Correction
Medical director of the facility was given the requirements for physicals and is developing a form. The clients were surveyed by their therapists to determine who has had a physical in the last six months. The clients will be given the form for their physical examination by their therapists to take to their physicans for completion of the physical examination or given to their physican when having a current physical examination. The date clients were given the form for their physical examination will be recorded in the chart by the therapists. The physical examination forms need to be returned and in the chart by November 1, 2013 for clients 1,2,4,5,6,7 and 8 and all other clients. New clients will be given the physical examination forms when they are completing their contract with the suboxone coodinator when they sign the contract and it must be returned prior to their first appointment with the doctor for induction. The suboxone coordinator will make sure that all new suboxone patients will receive a physical examination prior to having first appointment with the doctor for induction. |
711.92(c)(1) LICENSURE TX Plan Goals
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment, as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document the short-term goals for treatment as formulated by both staff and client in the individual treatment and rehabilitation plan in ten of fourteen patient records reviewed.The findings include:On September 20, 2013, fourteen patient records requiring documentation of long-term goals for treatment as formulated by both staff and client in the individual treatment and rehabilitation plan were reviewed. The facility did not document the long-term goals for treatment in ten of fourteen records reviewed, specifically, patient records # 1, 2, 4, 5, 6, 9, 10, 11, 12, and 13. Client # 1 was admitted February 26, 2013. The individual treatment and rehabilitation plan was completed on February 13, 2013, but it did not include documentation of the long-term goals for treatment as of September 20, 2013. Client # 2 was admitted May 22, 2013. The individual treatment and rehabilitation plan was completed on July 25, 2013, but it did not include documentation of the long-term goals for treatment as of September 20, 2013.Client # 4 was admitted June 5, 2013. The individual treatment and rehabilitation plan was completed on June 24, 2013, but it did not include documentation of the long-term goals for treatment as of September 20, 2013.Client # 5 was admitted March 21, 2013. The individual treatment and rehabilitation plan was completed on June 3, 2013, but it did not include documentation of the long-term goals for treatment as of September 20, 2013. Client # 6 was admitted April 18, 2013. The individual treatment and rehabilitation plan was completed on May 17, 2013, but it did not include documentation of the long-term goals for treatment as of September 20, 2013.Client # 9 was admitted February 22, 2013. The individual treatment and rehabilitation plan was completed on April 4, 2013, but it did not include documentation of the long-term goals for treatment as of September 20, 2013.Client # 10 was admitted April 30, 2013. The individual treatment and rehabilitation plan was completed on June 18, 2013, but it did not include documentation of the long-term goals for treatment as of September 20, 2013.Client # 11 was admitted March 28, 2013 and discharged on July 25, 2013. The individual treatment and rehabilitation plan was completed on June 19, 2013, but it did not include documentation of the long-term goals for treatment as of September 20, 2013.Client # 12 was admitted April 25, 2013 and discharged on July 23, 2013. The individual treatment and rehabilitation plan was completed on May 22, 2013, but it did not include documentation of the long-term goals for treatment as of September 20, 2013. Client # 13 was admitted March 7, 2013 and discharged on July 22, 2013. The individual treatment and rehabilitation plan was completed on April 15, 2013, but it did not include documentation of the long-term goals for treatment as of September 20, 2013. The findings were confirmed during an interview with the facility director on September 20, 2013 at approximately 4:00 P.M.This is a repeat citation. The facility was cited on October 10, 2012 for noncompliance with this standard.
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Plan of Correction
Therapist must all be using the new treatment plan which documents long and short term goals on the form or by October 19 the therapist will be writting the long or short term under the treatment goal section of the plan on a hand written form for clients 1,2,4,5,6,9 and 10 and all other hand written plans. This will be assessed by the clinical director each week when signing the treatment plans on an ongoing basis. If the treatment plans do not specify long or short term goals they will be returned to the therapist to be redone. This was reviewed with the therapists at a staff meeting September 24, 2013 |
711.96(a) LICENSURE Written Termination Notice
711.96. Notification of termination.
(a) The project director shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the project failed to notify the client in writing of a decision to involuntarily terminate the client's treatment at the project in two of two records reviewed. The findings include:On September 20, 2013, two client records requiring documentation that the project notified the client in writing of a decision to involuntarily terminate the client at the project were reviewed. The project failed to notify the client in writing of a decision to involuntarily terminate the client's treatment at the project in two of two records reviewed, specifically client records # 14 and 15.Client # 14 was admitted February 15, 2013 and involuntarily terminated July 24, 2013. Client # 14 was due to receive notification in writing of a decision to involuntarily terminate client # 14 from the project by July 24, 2013. However, client record # 14 did not include documentation of a decision to involuntarily terminate client # 14 from the project as of September 20, 2013.Client # 15 was admitted December 10, 2012 and involuntarily terminated April 23, 2013. Client # 15 was due to receive notification in writing of a decision to involuntarily terminate client # 15 from the project by April 23, 2013. However, client record # 15 did not include documentation of a decision to involuntarily terminate client # 15 from the project as of September 20, 2013. The findings were confirmed during an interview with the facility director on September 20, 2013 at approximately 4:00 P.M.
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Plan of Correction
The process for involuntary termination was reviewed at a staff meeting on September 24, 2013. The criteria for this classification of discharge was reviewed. The letter and required contents of the letter was reviewed for the staff. A copy of the letter was e-mailed to each staff member so that they had easy access to it and it was reviewed by each staff member. Clients 14 and 15 will be sent these termination letters by their program therapists by Qctober 24, 2013 and reveiwed by the clinical supervisor. These discharges will be reviewed once a month by the clinical director and they will be responsible for making sure that all clients who are involuntarily terminated receive a termination letters. |