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 August 26-27, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHJ Medical Center Inc. Vandergrift LLC 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 September 18, 2010.
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Plan of Correction
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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
Based on a review of active patient case lists, the narcotic treatment program monitoring questionnaire, and an interview with the facility director, the facility failed to maintain one FTE (full time equivalency) counselor for every 35 active patients.
The findings include:
On August 26-27, 2010, the narcotic treatment program monitoring questionnaire and active patient case lists were reviewed. Per regulation, the counseling caseload for one FTE counselor in an outpatient narcotic treatment program may not exceed 35 active patients. The current census of the facility is 228 patients. There are 172 active patients who are assigned to counselor caseloads. The facility had 56 active patients who were not assigned to a qualified counselor or counselor assistant; the facility assigned caseloads to two counselor assistants who were under direct observation and not qualified to maintain a caseload.
The facility director confirmed that the facility had 56 active patients that were not assigned to a qualified counselor or counselor assistant.
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Plan of Correction
The project director has ceased intakes until new counselor assistants meet the qualifications to be assigned a caseload. Once the direct observation period has been completed and the counselors are competant to be assigned a caseload intakes will be resumed. Until that time all other counselors will assist in patient care to ensure that patient care is of the highest quality. |
715.8(2) 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):
(2) Counselor assistants. A counselor assistant eligible for a counseling caseload may be included in determining FTE ratios.
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Observations
Based on a review of active patient case lists, the narcotic treatment program monitoring questionnaire, and an interview with the facility director, the facility failed to maintain one FTE (full time equivalency) counselor for every 35 active patients.
The findings include:
On August 26-27, 2010, the narcotic treatment program monitoring questionnaire and active patient case lists were reviewed. Per regulation, the counseling caseload for one FTE counselor in an outpatient narcotic treatment program may not exceed 35 active patients. The current census of the facility was 228 patients. Of these patients, 56 were assigned to staff that were not eligible to maintain a caseload.
Employee #6 is a counselor assistant currently supervised under direct observation and not eligilble for a patient caseload had an assigned caseload of 32 patients.
Employee #7 is a counselor assistant currently supervised under direct supervision and not eligible for a patient caseload had an assigned caseload of 24 patients.
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Plan of Correction
The project director has ceased all new intakes until the new staff members under direct observation have completed this phase and have established full competence to carry a caseload. At that time intakes will be resumed and the facility will be in compliance with this regulation. |
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 and an interview with the facility director, the facility failed to document an average of 2.5 hours of psychotherapy per month during the patient's first two years, in five of ten patient records.
The findings include:
Fourteen patient records were reviewed on August 26 - 27, 2010. Ten patient records were required to document an average of 2.5 psychotherapy hours per month. Four patients are not applicable for 2.5 hours a month of psychotherapy. Per regulation, 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. The facility failed to document an average of 2.5 hours of psychotherapy per month in patient records # 1, 2, 5, 7, and 14.
Patient represented by record # 1 was admitted into treatment on April 14, 2010. The patient attended only 1.5 hours of therapy in July 2010.
Patient represented by record # 2 was admitted into treatment on May 21, 2010. The patient attended only 1.5 hours of therapy in June 2010.
Patient represented by record # 5 was admitted into treatment on July 7, 2009. The patient attended only 1.5 hours of therapy in June 2010.
Patient represented by record # 7 was admitted into treatment on July 10, 2009. The patient attended only 1.5 hours of therapy in June 2010.
Patient represented by record # 14 was admitted into treatment on December 7, 2009, and was discharged on June 24, 2010. The patient attended only 1.5 hours of therapy in May 2010.
The facility director confirmed that a minimum of 2.5 psychotherapy hours per month did not occur in five of the records..
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Plan of Correction
The counselor that left was replaced by a new counselor who will complete direct observation period and be assigned a caseload until then all other counselors will attempt to ensure that the counseling requirements our met to the best of our ability. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of the patient records, the facility failed to document the signature of the medical director on the annual evaluation in two of the five patient records reviewed.
The findings include:
Fourteen patient records were reviewed on August 26-27, 2010. Five of the fourteen patient records are required to include an annual evaluation. Three patient records have annual evaluations that include the signature of the medical director. Two of the five records failed to include the medical directors signature on the annual evaluation.
Patient record # 5 was admitted to treatment on July 7, 2009. The annual evaluation was completed on July 7, 2010. The evaluation was signed by the narcotic treatment physician, but was not signed by the medical director as required.
Patient record # 10 was admitted to treatment on March 5, 2009 and was discharged on July 26, 2010. The annual evaluation was completed on March 5, 2010. The evaluation was not signed by the medical director as required.
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Plan of Correction
The facility director will meet with staff to inform them of the regulation and direct staff to ensure that the medical director is the only physician who is able to sign the annual review. The facility director will also meet with all attending physicians and inform them that only the medical director is able to complete the annual evalutation. To ensure continued compliance random audits will be completed and further instuction will be provided as necessary.
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