INITIAL COMMENTS
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This report is the 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 February 8-10, 2011 by staff from the Division of Drug and Alcohol program licensure. Base on the findings of the on-site inspection, Lebanon Treatment Center 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 the site inspection and a plan of correction is due on March 9, 2011.
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Plan of Correction
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on a review of administrative documentation and discussions with administrative staff, the facility failed to ensure physician services at least one hour for every ten patients per week on site.The findings include:Administrative documentation was reviewed on February 8, 2011. This included the physician and physician extender's work schedules. During the week of October 30, 2010, the physician hours totaled 7 hours and the physician extenders' hours totaled 9 for a total of 16 hours. Patient census was 210; the facility was required to have at least 21 hours of physician services during this time frame.During the week of November 6, 2010 physician hours totaled 8.5 hours and physician extender ' s hours totaled 7 hours for a total of 15.5 hours. Patient census was 211; the facility was required to have at least 21.1 hours of physician services during this time frame During the week of November 27, 2010 physician hours totaled 8.5 hours and physician extenders hours totaled 7 hours for a total of 17.5 hours. Patient census was 214; the facility was required to have at least 21.4 hours of physician services during this time frame.During the week of December 25, 2010 physician hours totaled 8.5 hours and physician extenders hours totaled 12 hours for a total of 20.5 hours. Patient census was 211; the facility was required to have at least 21.1; hours of physician services during this time frame.During the week of January 30, 2011 physician hours totaled 8.5 hours and physician extender hours totaled 10 hours for a total of 18.5 hours. Patient census was 201; the facility was required to have at least 20.1 hours of physician services during this time frame.+A discussion occurred with the project director on February 10, 2011. It was confirmed that, per regulation, physician services were not provided at least one hour for every ten patients.
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Plan of Correction
Increased efforts will be made by Medical Director and Physician Extenders to ensure that the 1 hour to ten patient ratio is met. Lebanon Treatment Center will schedule at least 1 physician hour per ten patients moving forward. Nursing Supervisor will be responsible for ensuring that we meet this ratio accordingly. Nursing Supervisor will review the medical work schedule with campus director on a monthly basis to ensure compliance. This plan is to take effect 2/28/11 and is an on-going effort. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on a review of patient records and a discussion with administrative staff, the facility failed to document follow-up in accordance with facility policy in 4 of 5 patient records.The fining include. Five patient records were reviewed for follow up attempts in accordance with the facility policy. Facility policy stated that "patients who are discharged and successfully completed the program will be contacted by utilizing the following method .... within 30 days post discharge .... mail a a Post Discharge Treatment Evaluation form to the former patients. CRC/ATS will follow patients who have left the program before completion by telephone within fourteen days of leaving "Patient # 1 was admitted on 4/12/10 and discharged on 10/27/10. There was no documentation of follow-up in the patient record.Patient #2 was admitted on 8/14/10 and discharged on 1/25/11. There was no documentation of follow-up in the patient record.Patient #3 was admitted on 6/9/08 and discharged on 12/15/10. There was no documentation of follow-up in the patient record.Patient # 9 was admitted on 1/29/07 and discharged on 10/1/10. There was no documentation of follow-up in the patient record.A discussion with the project director and regional director on February 10, 2010, confirmed that the follow-up was not completed according to facility policy.
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Plan of Correction
A Post Discharge Treatment Evaluation Form will now be sent to all patients within 30 days of discharge per policy. This correspondence will be tracked and documented by Office Manager to ensure compliance. Officer Manager will review the correspondence log with campus director on a monthly basis to ensure compliance. This plan of correction is to be enacted on 2/28/11 and is an on-going effort. |