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 June 17-18, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Alliance medical Services 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 July 20, 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 discussion with staff, the facility failed to ensure physician staffing at least one hour per week onsite for every ten patients during one of five months reviewed. The findings include:Administrative documentation that included physician and physician extender time logs were reviewed on June 17, 2009. During the week of May 25, 2009, which included a holiday, the staff #10 logged eight (8) onsite hours. There were no documented hours for staff #11 the week of May 25, 2009. The census did not go below 150 patients during this time frame and the facility needed 15 hours of physician services for the week. The facility documented the availability of a PRN physician, but did not utilize him to make up the hours during this timeframe.
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Plan of Correction
The facility did not provide the required physician hours for a census of 219 patients. The facility is required to provide a minimum of 22 physician hours for 219 patients. Regardless of the census, the physician is required to provide 1 hour of service for every 10 enrolled patients.
The Facility Director will be responsible to adjust the physicians schedule to meet the requirement of 22 hours. The physician will provide the necessary coverage. The Facility Director will be responsible for ongoing compliance through regular review of the physician timesheets.
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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 administrative documentation, the facility failed to comply with the counseling caseload ratio. The findings include:Administrative documentation including counselor caseload records and hours worked was reviewed on June 17, 2009. Counselor # 9 worked part time hours, averaging 20 hours weekly. The counselor's caseload was listed as 20 patients, bringing the the FTE caseload to 38/1, exceeding the maximum 35/1.
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Plan of Correction
The facility did not comply with the counseling caseload ratio.
The counselor to patient ratio for a full time employee is 35:1. Part time employess with a reduced caseload are to adhere to this ratio formula based on the number of active patients on their caseloads with a corressponding number of hours worked. In this case part time counselors had an excessive number of active cases for the number of hours worked.
The facility Director is responsible to train the clinical supervisor to increase or decrease working hours for part time employess based on the size of the caseload and adjust payroll according to the established ratio. The Facility Director is responsible for oversite in this matter and will follow up with training as necessary.
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715.17(c)(1)(i-vi)) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(1) Administration of medication.
(i) A narcotic treatment physician shall determine the patient 's initial and subsequent dose and schedule. The physician shall communicate the initial and subsequent dose and schedule to the person responsible for the administration of medication. Each medication order and dosage change shall be written and signed by the narcotic treatment physician.
(ii) An agent shall be administered or dispensed only by a practitioner licensed under the appropriate Federal and State laws to dispense agents to patients.
(iii) Only authorized staff and patients who are receiving medication shall be permitted in the dispensing area.
(iv) There shall be only one patient permitted at a dispensing station at any given time.
(v) Each patient shall be observed when ingesting the agent.
(vi) Administering and dispensing shall be conducted in a manner that protects the patient from disruption or annoyance from other individuals.
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Observations
Based on the review of patient records, the facility failed to ensure each medication order and dose change was written and signed by the narcotic treatment physician in three of twelve patient records. The findings include:Twelve patient records were reviewed on June 17-18, 2009. Documentation by physician for medication orders and dose changes was required in twelve patient records. Patient record # 14 contained a blank dose adjustment form for an order entered on April 26, 2009. There was no indication of a specific dose change on the the order. Patient records # 2 and 12 contained the physician order forms completed by someone other than the physician, and then signed by the physician.
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Plan of Correction
The physician is responsible for determining the dosage on all patients. As part of the process, the counselor completes the dosage change request form with the patient. This form is submitted to the physician and after evaluating the case record, request form, and any other pertinent data will order the dosage change. This will pertain to routine requests for increase or decrease in dosage as well as any administrative discharge process. The physician will document this order in the electronic record for dosing which will record the amount adjusted and in the case of administrative detoxification the length and decrease of dosage schedule. Upon completion of the order the physician will provide his signature as verification.
Training will be provided to counseling staff to clearly understand their role as consultative and to provide information pertinent to the case in order to assist the physician to make the necessary determination regarding any medical orders related to dosage adjustment. The Clinical Supervisor and Medical Director will provide training to all counseling staff as it relates to this issue.
The Facility Director is responsible for oversite and compliance through routine inspection of the written order documentation. |
715.23(b)(22) LICENSURE Patient records
(b) Each patient file shall include the following information:
(22) Aftercare plan, if applicable.
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Observations
Based on a review of patient records, the facility failed to document a complete aftercare plan in 1 of 1 records. The findings include:Twelve patient records were reviewed on June 17-18, 2009. One record required an aftercare plan. Record # 8 contained an aftercare plan that did not include a date when completed, signatures of either staff or the patient to demonstrate that the patient participated or received the plan, and timeframes for the established goals.
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Plan of Correction
A complete aftercare plan was not documented in an discharged patients file as required.
It is the responsibility of the individual counselor to complete an aftercare plan prior to discharge. The plan should be completed through discussion and input from both the patient and the counselor and allow for time to work through any resistance and determine practical solutions. Timeframes for the established goals must be included. The plan must be signed by the patient and counselor and be dated prior to discharge. The patient will be provided with a copy.
The clinical supervisor will provide training on completion and utilization of the aftercare plan to all counseling staff. The supervisor will follow through with regular review of patient records and utilize supervision for compliance and further training if necessary. It is the responsibility of the Facility director to ensure that this process is carried out and satisfactory. |
715.23(e) LICENSURE Patient records
(e) Patient file records, information and documentation shall be legible, accurate, complete, written in English and maintained on standardized forms or electronically.
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Observations
Based on the review of patient records and staff interviews, the facility failed to ensure documentation was legible and complete in 12 of 12 patient records. The findings include:Twelve patient records were reviewed on June 17-18, 2009. Twelve records required legible handwriting. Staff # 11's handwriting was illegible in all patient records reviewed. Nursing staff was interviewed on June 17, 2009 and the nursing staff reported having to request a verbal report of staff #11's documentation because they were unable to read thisstaff person's written documentation.
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Plan of Correction
Alliance Medical Services failed to ensure documentation was legible and complete in 21 of 21 patient records. The physician documentation was not legible and in some cases incomplete.
It is the responsibility of the physician to write and complete orders in a manner understandable to all staff. The Facility Director will meet with the physician and review the POC. The discussion will focus on the necessity of the physician to write legibly and that all orders are to be complete. The Facilty Director will conduct ongoing monitoring of compliance in this regard and will provide further direction to the physician as needed. |
715.23(f) LICENSURE Patient records
(f) If a narcotic treatment program keeps patient information in more than one file or location, it is the responsibility of the narcotic treatment program to provide the entire patient record to authorized persons conducting narcotic treatment program approval activities at the narcotic treatment program, upon request.
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Observations
Based on observation and staff interview, the facility failed to provide the entire record upon request. The findings include:Patient records were requested about 8:30 AM on June 18, 2009. At approximately 9:35-9:40 AM, staff #13 came to the office where the authorized persons were performing the record review. He had, in his possession, a stack of blue patient medical records. He informed the authorized persons that he could not present these records prior to a review by the the physician extender. The authorized person informed him that the patient records were required to be submitted for official review and requested that the staff person provide the patient records he had in his possession. He refused, stating that it was the facility's internal policy to first review the records before passing them on to the authorized persons for review.
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Plan of Correction
The facility did not present the entire record at the time of request.
There is no internal policy regarding the review of records prior to passing them on to authorized persons.
The Facility Director has provided training to the clinical supervisor and staff to clarify that records are to be submitted to authorized persons upon request. Further, training was provided to guarantee that records should always be current and that the supervisor will utilize regular record review as the required tool to gain compliance.
The Facility Director is responsible to insure that this process remains consistent and that the supervisor complies with all requests for records from authorized persons. |