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 January 29 and 30, 2008 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 in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on February 27, 2008.
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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 facility documentation and staff interviews, the facility failed to ensure that 57 patients had an assigned counselor.
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Plan of Correction
Due to a counselor who resigned in January 2008 we were without a staff member, (counselor) thus why we had clients unassigned to a primary counselor during the time of our visit.
We have been approved for the counselor ratio exception and will utilize this exception especially when we have a shortage of clinical staff.
The clinical supervisor and facility director, (both meet counselor requirements) will fill in when ever needed to ensure that all clients are seen by a counselor. Due to the other tasks required of these positions, clients who do not have a primary counselor and are stable in treatment will be monitored by these staff members.
If we had an open clinical caseload one of the steps the clinical supervisor will complete is too develop a caseload that prioritize clients based upon stability in treatment. This will ensure those clients with the greatest needs are assigned a primary counselor right away and can continue to be monitored closely
We are currently interviewing for the position. We have decided to hire a full time counselor and/or counselor assistant and add a part time counselor and/or counselor assistant) to our staff. With a part time staff member we would have the flexibility of increasing their caseload if we were to be short staffed clinically thus preventing ratio non compliance as well as ensuring client's treatment is being monitored.
We plan to have these positions filled by 2/29/08(Sooner if possible).
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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of 22 patient records, the physician failed to document a face-to-face determination of current dependence for patients # 2, 9 and 20. Additionally, for patient # 11 the facility physician failed to document that the patient was currently dependency on opioid drugs.
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Plan of Correction
We have already corrected this issue.
First a meeting with our MD was held to discuss his documentation. At this time a new form was given to him and reviewed by director that made a few changes with wording, (as suggested by licensing specialist) to ensure that MD is completing documentation correctly.
We believe MD is performing tasks but his documentation was not reflecting this.
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715.9(b)(2) LICENSURE Intake
(b) Exceptions to the requirements in subsection (a) are:
(2) Upon readmitting a patient who has been out of a narcotic treatment program for 6 months or less after a voluntary termination, the narcotic treatment program shall update the information in and review the patient 's file to show current opiate narcotic dependency, but need not conduct a physical examination and applicable laboratory tests. Privileges earned during the previous treatment may be reinstated at the discretion of the narcotic treatment physician.
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Observations
Based on a review of the facility manual, the facility failed to address in their policy and procedures that documentation of current dependency is required at readmission.
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Plan of Correction
On February 4, 2008, Director completed a review of our policy and procedure manual. Specifically reviewing documentation of current dependency upon readmission, policy was corrected to include that current dependency is required at readmission
On February 5, 2008 management staff reviewed readmission process with director to ensure staff understanding of the procedure/standard.
On February 5, 2008 The management staff completed a review of clients who were readmitted into treatment under this standard within the last year. Upon review of these charts, we did not admit anyone without determining current dependency.
Director believes that all staff were trained and understood the procedure for readmissions under six months as stated by regulation and that the manual's policy was written incorrectly
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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
Observation of the methadone dispensing revealed that the facility failed to ensure patient confidentiality. The returned take-home bottles that included the patient's full name, the number of milligrams of methadone, the prescribing physician's name and the facility name were discarded in a non-secured trash container.
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Plan of Correction
During management meeting on February 5, 2008 this issue was discussed and it was determined that the clients will need to use a black sharp pen and cross off their personal information on each bottle returned at the nursing window.
All staff were informed of this change and clients were informed of this change at the dosing window, in the monthly newsletter and when in session with thier primary counselor.
We began to use this process to ensure client confidentiality on February 6, 2008. |
715.16(a)(5) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(5) A narcotic treatment program shall develop written policies and procedures relating to granting and rescinding take-home medication privileges.
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Observations
Based on a review of the policy and procedure manual, the facility failed to address the patient call backs that were required as a condition of the exception for take-home privileges. Specifically, facility policy specified quarterly call backs for the first year with twice a year call backs in subsequent years; the exception requires quarterly call backs in all circumstances when a patient is receiving take-home privileges through an exception. Additionally, there was no facility policy that addressed urinalysis results that were positive for an illicit substance and the impact this has on the patient's continued eligibility for take-home privileges.
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Plan of Correction
On February 4, 2008 director and medical director reviewed current take home policy. We used the state regulations and compared our written policy to ensure compliance.
Although a process was documented regarding a client producing an illicit urine profile, we expanded this to allow for very specific guidelines to use when dealing with illicit urines and clients take homes especially under an exception.
Also, all clients who have extended take homes have had the required amount of call backs as defined by state standards. The policy/procedure was amended to reflect this process.
All staff were given a written copy of our updated take home medication policy on February 5, 2008. The changes were presented and discussed by director and MD with the staff to ensure understanding of the standard/procedures.
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715.21 LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
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Observations
Based on random review of 22 patient records, the facility failed to ensure all efforts had been initiated to retain the patient prior to the involuntary termination. Patient # 11, was admitted on August 20, 2007 and was given a ten day notice of involuntary detoxification on January 4, 2008 for failure to follow treatment plan, specifically for not maintaining financial obligations to the facility. The patient appealed the process due to her pregnancy and the process to involuntarily discharge the patient was stopped. A review of patient records did not indicate the patient was provided with treatment options ( to address her inability to pay ) prior to her notice of termination.
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Plan of Correction
The director with the assistance of management staff has recreated the process of involuntary detoxification notices. First, all reasons for termination from treatment has been updated to ensure compliance with the four reasons to why a client could be detoxed from treatment.
We recreated forms and our process so that a client who has any issues with treatment has a few steps that they may use to assist with correcting these issues or finding a form of treatment that better suits their needs. As well as allow staff to document the amount of work they did with the client in solving the problem
The first step is notification of the problem, the primary counselor and/or the clinical supervisor will meet with the client to discuss our concerns and make an attempt to assist the client with solving the problem.
If this would not provide a resolution we would move on to the next step which would require the client to schedule a meeting with the intervention committee. At this meeting information will be gathered to determine what the client needs are so staff are able to assist with the resolution of the problem.
A written plan that would assist the client with solving issue (s) will be given to the client (the plan will be discussed with the client to ensure understanding and all present would sign the plan) at that time. Along with this plan any referrals recommended by the intervention committee would be given to the client.
The primary counselor will assist the client is meeting goals of the plan.
If the client fails to follow/successfully complete the intervention plan the next stop will be a notice of appeal. At this meeting, again the staff will work with the client to find out their issues/concerns, develop a plan to help correct the problem so client could avoid detoxification.
These plans will have specific dates that certain goals will need to be met by the client. T
We have created an information form that will be given to all clients that includes medical assistance numbers, addresses, clinic addresses, list of drug free treatment facilities and county SCA offices.
We do not detox pregnant clients and director is not sure why this client was given a notice of detox. After discussion with licensure staff alternative tools were given to us that we could use to assist a client who is having trouble in treatment, especially pregnant women.
All Staff were trained and this new process was implemented on February 18, 2008.
We do believe we work with all of our clients a great deal to keep them in treatment. This process allows us to work with the clients, document all of our work that we do with the clients, takes away clients anxiety regarding being detoxed and gives the client a useable plan and information that could assist in continuing their treatment.
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715.21(1)(i-iv) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
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Observations
Based on a review of program documentation and policies and procedures, the facility failed to develop reasons for possible termination that were consistent with the standards. Specifically, facility policy exceeded the standards and included the following reasons for termination: loitering, property destruction, altered urine specimen, missed counseling appointments, and attempting to remove methadone from the building.
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Plan of Correction
Upon review of forms by director, it was noted that our notice of detoxification form had these reasons listed on the top, but all other documentation, (policy, staff training, intake forms, etc) were in compliance with standards regarding involuntary detoxification.
The notice of detoxification was updated to reflect the four reasons a client can be involuntary terminated from treatment. All staff were given new forms on February 5, 2008, by the director, all old forms were destroyed.
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715.23(d)(1) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(1) The treatment plan shall identify the behavioral tasks a patient shall perform to complete each short-term goal.
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Observations
The facility failed to develop treatment plans that contained short term goals with measurable steps. The treatment plans failed to identify support systems needed by the patient. Based on a review of 22 patient records, patients # 3, 4, 7, 8, 9, 11, 13, 17 and 18 did not have measurable tasks to be completed by the patient to accomplish the short term goals.
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Plan of Correction
The facility has been working on treatment plan goals with staff for some time. Director and Clinical supervisor are signed up for an on line treatment planning course sponsored by ATTC. The class was supposed to begin in January 2008 but has been delayed until the spring. Director is in contact with the local ATTC office; staff are paid and registered for the class.
We hope that this course gives management staff some ideas of how to assist the clinical staff in writing treatment plan goals.
Also, Director has obtained a three part series created by ATTC in 2006, regarding treatment planning. It is series 22 and has three parts, "creating a living document", "make a smart plan" and "putting it all together". Director and clinical supervisor have reviewed the information have decided to use the information as an in house training for clinical staff.
For three weeks, one part of the series will be given to clinical staff in an in house in-service training each week.
This series provides exercises and a quiz at the end. The first training will begin the week of February 18, 2008; the whole training will be completed by the week of March 3, 2008. Staff will be required to complete an in-service evaluation which will be given to the director to determine if it was helpful to them.
Again we are hoping that this helps clinical staff gain a better understanding in treatment planning.
Clinical supervisor reviews each plan and has been meeting with staff to discuss their treatment plans on a weekly basis. Plans are being returned to counselors if the goals and steps are not able to be measured.
The development of treatment plans continues to be part of clinical staffs individual training plans thus is discussed often.
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715.23(d)(2) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
(2) The narcotic treatment physician or the patient 's counselor shall review, reevaluate, modify and update each patient 's treatment plan as required by Chapters 157, 709 and 711 (relating to drug and alcohol services general provisions; standards for licensure of freestanding treatment activities; and standards for certification of treatment activities which are a part of a health care facility).
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Observations
Based on a review of 22 patient records, the facility failed to document new patient goals and updates that were realistic and specific to patient needs, specifically, patients #4, 7, 18 and 20.
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Plan of Correction
This relates to previous citation for treatment plans and we are hoping that the plan of correction we have created for that citation will assist the clinical staff with this citation so they will be able to write specific new patient goals that are realistic and specific to their individual clients needs.
The facility has been working on treatment plan goals with staff for some time. Director and Clinical supervisor are signed up for an on line treatment planning course sponsored by ATTC. The class was supposed to begin in January 2008 but has been delayed until the spring. Director is in contact with the local ATTC office; staff are paid and registered for the class.
We hope that this course gives management staff some ideas of how to assist the clinical staff in writing treatment plan goals.
Also, Director has obtained a three part series created by ATTC in 2006, regarding treatment planning. It is series 22 and has three parts, "creating a living document", "make a smart plan" and "putting it all together". Director and clinical supervisor have reviewed the information have decided to use the information as an in house training for clinical staff.
For three weeks, one part of the series will be given to clinical staff in an in house in-service training each week.
This series provides exercises and a quiz at the end. The first training will begin the week of February 18, 2008; the whole training will be completed by the week of March 3, 2008. Staff will be required to complete an in-service evaluation which will be given to the director to determine if it was helpful to them.
Again we are hoping that this helps clinical staff gain a better understanding in treatment planning.
Clinical supervisor reviews each plan and has been meeting with staff to discuss their treatment plans on a weekly basis. Plans are being returned to counselors if the goals and steps are not able to be measured.
The development of treatment plans continues to be part of clinical staffs individual training plans thus is discussed often.
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