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 October 19-20, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, WPIC Narcotic Addiction Treatment Program 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 November 20, 2009.
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Plan of Correction
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715.20(3) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document what materials were sent to the receiving narcotic treatment program in two of two patient records.
Findings
Sixteen patient records were reviewed on October 19-20, 2009. Two patient records were reviewed as patient transfers to other programs. There was no documentation in patient records # 15 and 16 that showed the narcotic treatment program had sent material to the receiving narcotic treatment program.
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Plan of Correction
The Clinical Supervisor will ensure, through quality assurance chart review and direct supervision that the transferring narcotic treatment program clearly documents what materials were sent to the receiving narcotic treatment program.
Effective December 2, 2009 clinical staff will be required to complete a new form entitled 'Acknowledgement of Transfer from NATP' upon the completion of transfer material to the receiving narcotic treatment program.
The form, and the necessity of its inclusion, will be presented to staff during a scheduled staff meeting on December 1, 2009.
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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 the review of patient records, the facility failed to document an annual evaluation of each patient's status that was reviewed, dated and signed by the medical director in one of five patient records.
Finding:
Sixteen patient records were reviewed on October 19-20, 2009. Five patient records reviewed were required to have an annual evaluation completed by the patient's counselor and reviewed, dated and signed by the medical director. There was no documentation in patient record # 14 that showed the medical director had reviewed, dated and signed the annual evaluation.
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Plan of Correction
The Clinical Supervisor will ensure, through quality assurance chart review and direct supervision that the completed annual evaluations have been reviewed, dated and signed by the medical director prior to being placed in the client record.
Upon the therapist completing the evaluation, he will place a copy in a designated area for the medical director to review, sign and date. After the medical director has completed, form will be filed in record.
Moreover, a report that lists all clients who are due for an annual evaluation will be generated monthly. The Clinical Supervisor, or his designed will use the list to ensure all evaluations are complete and that the medical director has reviewed, dated and signed the annual evaluation.
This information will be shared with clinical staff at a staff meeting to be held December 1, 2009. Process will begin immediately thereafter.
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