INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 9-11, 2014 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 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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709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on the review of client records, the facility failed to document that verbal medication orders were signed within 24 hours by the prescribing physician in one of four client records. The findings include:Nineteen client records were reviewed on September 9-11, 2014. Four client records reviewed documented verbal orders. The verbal order was not signed by the prescribing physician within 24 hours in client record # 3.Client # 3 was admitted on May 14, 2014. A verbal order was documented by the nurse on May 17, 2014 @ 6:25 AM. The order was signed by the prescribing physician on May 19, 2014. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
NTP physician will sign off on all verbal orders within 24 hours beginning immediately.
Nursing staff will ensure above compliance during random monthly medical chart audits.
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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 the review of client records, the facility failed to document that the patient received an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, which included 1 hour of individual psychotherapy in five of thirteen patient records. The findings include:Nineteen client records were reviewed on September 9-11, 2014. Thirteen patient records required documentation an average of 2.5 hours of psychotherapy per month which included 1 hour of individual psychotherapy. There was no documentation of 1 hour of individual psychotherapy in patient records # 1, 6, 7, 8 and 12. Patient # 1 was admitted on February 25, 2014. There was no documentation of 1 hour of individual psychotherapy for the months of June and August, 2014. Patient # 6 was admitted on March 26, 2014. There was no documentation of 1 hour of individual psychotherapy for the month of June, 2014. Patient # 7 was admitted on April 29, 2014. There was no documentation of 1 hour of individual psychotherapy for the month of June, 2014. Patient # 8 was admitted on June 25, 2013. There was no documentation of 1 hour of individual psychotherapy for the month of July, 2014. Patient # 12 was admitted on December 12, 2013 and discharged on June 23, 2014. There was no documentation of 1 hour of individual psychotherapy for the month of March, 2014. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PD and clinical supervisor re-iterated to counselors that clients must receive at least 1 hour of individual therapy per month during the first 2 years of treatment.
Program Director and clinical supervisor will randomly monitor charts and review the client hour's grid monthly to ensure compliance.
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709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) 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 the review of client records, the facility failed to document long- term goals for treatment on the individual treatment and rehabilitation plan in six of ten client records reviewed. The findings include:Nineteen client records were reviewed on September 9-11, 2014. Twelve of those records were reviewed as outpatient records. Of the twelve client records, ten client records required documentation of an individual treatment and rehabilitation plan which included long-term goals for treatment. There was no documentation of long-term goals in client records # 2, 4, 7, 8, 9 and 10. Client # 2 was admitted on January 20, 2014. An individual treatment and rehabilitation plan completed on March 17, 2014 did not include long-term goals. Client # 4 was admitted on March 26, 2014. An individual treatment and rehabilitation plan completed on April 9, 2014 did not include long-term goals. Client # 7 was admitted on December 12, 2013. An individual treatment and rehabilitation plan completed on February 27, 2014 did not include long-term goals. Client # 8 was admitted on December 26, 2013. An individual treatment and rehabilitation plan completed on January 2, 2014 did not include long-term goals. Client # 9 was admitted on December 16, 2013. An individual treatment and rehabilitation plan completed on January 8, 2014 did not include long-term goals. Client # 10 was admitted on November 12, 2013. An individual treatment and rehabilitation plan completed on January 2, 2014 did not include long-term goals. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PD added a statement on the treatment plan prompting counselors to add long-term treatment goals. Staff training and implementation will occur by 10/2/14.
The new format will clearly identify treatment plan long term treatment goals.
Implementation of the new form will provide for correction of current deficient treatment plans.
Program director and clinical supervisor will monitor accuracy when reviewing treatment plans during random monthly chart audits.
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