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 November 16-17, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Progressive Medical Specialists, Inc was found not to be compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and a plan of correction is due on December 18, 2009. .
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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 the review of administrative documentation and staff interviews, the facility failed to provide at least one hour of physician time a week, on site for, every ten patients.
The findings include:
Physicians time sheets and and census reports for the months of August, September, October and November 2009, were reviewed on November 16, 2009. The interview with staff occurred on November 16, 2009. The facility is licensed to medicate 360 patients and the census did not go below 355 patients during the time period reviewed. The physician's hours documented were insufficient for the weeks of August 3, 10, 17, September 7, October 5, 12, 19 and November 2, 2009.
During the week of August 3, the total physician time required was 36 hours. The total physician time documented was 35 hours.
During the week of August 10, 2009, the total physician time required was 36 hours. The total physician time documented was 35.5 hours.
During the week of August 17, 2009, the total physician time required was 36 hours. The total physician time documented was 35.5 hours.
During the week of September 7, 2009, the total physician time required was 36 hours. The total physician time documented was 30 hours.
During the week of October 5, 2009, the total physician time required was 36 hours. The total physician time documented was 35 hours.
During the week of October 12, 2009, the total physician time required was 36 hours. The total physician time documented was 35 hours.
During the week of October 19, 2009, the total physician time required was 36 hours. The total physician time documented was 35 hours.
During the week of November 2, 2009, the total physician time required was 36 hours. The total physician time documented was 34.5 hours.
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Plan of Correction
Every Wednesday the medical director and project director will review the hours completed for the week to determine how many hours are needed to ensure the 1 to 10 ratio is met weekly.
A schedule will be created for the remaining days of the week that will ensure the correct number of medical hours is obtained consistently.
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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 the review of the counselor assistants' caseloads, the facility failed to comply with the staffing regulation which states that the counseling caseload for one FTE counselor in an outpatient narcotic treatment program may not exceed 35 active patients.
Finding:
The counselor assistants' caseloads were reviewed on November 16-17, 2009. The facility included the counselor assistants in the reduced caseload ratios. Counselor assistants are not eligible for a reduced caseload. Caseloads exceeded 35 to 1 for six of the eight counselor assistants.
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Plan of Correction
From the licensing visit held in August 2009 director had thought counselor client ratios were being completed correctly.
Clinical supervisors and project director removed clients from all counselor assistants who had an active caseload that exceeded the allowed amount of 35 clients.
Clients were placed on caseloads with counseling staff who meet exception requirements.
Counselor supervisors will ensure that counselor assistants maintain a caseload of 35 active clients by using the counselor active caseload list generated by our computer program when assigning new clients, (reviewed at least weekly by clinical supervisors)
Project director will continue to use monthly tracking sheets to complete client counselor ratios. This tracking sheet allows director to review the number of clients assigned to each counselor thus a monthly review of each caseload will be completed to ensure compliance.
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715.10(c) LICENSURE Pregnant patients
(c) Counseling records and other appropriate patients records shall reflect the nature of prenatal support provided by the narcotic treatment program.
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Observations
Based on a review of patient records, the facility failed to ensure that pregnant patients' records reflect the nature of prenatal support provided by the narcotic treatment program.
Findings:
Eighteen patient records were reviewed on November 16-17, 2009. One patient record was reviewed as a pregnant patient. Patient record #1 was missing clinical documentation relating to the nature of prenatal support provided by the narcotic treatment program.
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Plan of Correction
This was an oversight of one newer counselor. We were informed of this goal missing by State inspectors on 11/16/2009.
On 11/17/2009 Clinical supervisor met with counselor to discuss treatment plan goals and pregnant women again.
Counselor created a new treatment plan on 11/17/2009 with this client that includes prenatal support
Clinical and nurse supervisors are aware of all pregnant women actively in treatment. Therefore when the clinical supervisor reviews and signs treatment plans goals she can review these goals to ensure that prenatal issues are being addressed.
Also, clinical charts are reviewed quarterly by clinical supervisor and/or project director. An audit sheet in the form of a checklist is used and filed with the results of the audit. Project director added a specific area that is for pregnant women specific issues which includes a check to ensure prenatal issues are being addressed in treatment consistently.
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715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
Based on a review of patient records, the facility failed to document an informed and voluntary consent to release information in eight of fourteen patient records.
The findings include:
Eighteen patient records were reviewed on November 16-17, 2009. Fourteen patient records were required to have documentation of an informed and voluntary consent to release information. The release of information forms specified the patient could revoke the consent in writing; but did not include the patient could also revoke the consent verbally. This consent to release information form was found in patient records: # 1, 2, 3, 4, 5, 6, 7 and 8.
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Plan of Correction
On November 16, 2009 State inspectors questioned why verbal voiding of a release of information was not on our current release of information forms.
As a result, on 11/17/2009 all current releases used by the facility were updated by project director to include verbal revocation of a release of information.
All updated releases were given to staff members to begin using on 11/17/2009. |
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 provide each patient with the minimal requirement of an average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment.
Findings:
Eighteen patient records were reviewed on November 16-17, 2009. Seven patient records were required to have an average of 2.5 hours of psychotherapy per month during the patient's first 2 years. Patient records # 1, 4, 5, and 9 were missing documentation that the patient had received an average of 2.5 hours of psychotherapy per month.
Patient record # 1 documented an average of 1.94 hours.
Patient record # 4 documented an average of 1.78 hours.
Patient record # 5 documented an average of 1 hour.
Patient record # 9 documented an average of 1.88 hours.
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Plan of Correction
It was decided that the clinical supervisor will meet with each counselor/counselor assistant after the first full two weeks of each month to review their monthly tracking sheets.
Currently, each clinical staff member monitors due dates, counseling time etc, for each client on their caseload on a monthly tracking sheet that is turned into the director the first of each month.
The clinical supervisor can quickly review each client's counseling time completed to date and be able to indentify those client that are not receiving the required amount of counseling time, thus allowing each counselor at least two weeks to ensure compliance with the individual's counseling time.
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715.19(2) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(2) A narcotic treatment program shall provide each patient at least 1 hour per month of group or individual psychotherapy during the third and fourth year of treatment. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on the review of patient records, the facility failed to provide each patient with at least 1 hour of group or individual psychotherapy every 2 months after 4 years of treatment.
The findings include:
Eighteen patient records were reviewed November 16-17, 2009. Three patient records were reviewed for at least one hour of group or individual psychotherapy every 2 months.
In patient record #10, the patient was required to have 1 hour of psychotherapy for the month of October, 2009. Documentation shows the patient received 50 minutes of psychotherapy for the month of October, 2009.
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Plan of Correction
It was decided that the clinical supervisor will meet with each counselor/counselor assistant after the first full two weeks of each month to review their monthly tracking sheets.
Currently, each clinical staff member monitors due dates, counseling time etc, for each client on their caseload on a monthly tracking sheet that is turned into the director the first of each month.
The clinical supervisor can quickly review each client's counseling time completed to date and be able to indentify those client that are not receiving the required amount of counseling time, thus allowing each counselor at least two weeks to ensure compliance with the individual's counseling time.
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