INITIAL COMMENTS
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This report is a result of an on-site inspection for the approval to use a narcotic agent, specifically Methadone, in the treatment of narcotic addiction. This inspection was conducted on March 10, 2015 by staff of 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:
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Plan of Correction
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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 the review of patient records, the facility failed to 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 in one of eight patient records. The findings include:Thirteen patient records were reviewed on March 10, 2015. Eight patient records were reviewed for the 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 facility did not document this requirement in patient record # 11.Patient # 11 was admitted on November 13, 2014 and discharged on January 29, 2015. The patient was first dosed on November 14, 2014. The face-to-face determination of whether the individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission was documented on November 17, 2014.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility did not provide the physician's determination of opiate dependency prior to admission.
The Physician is required to make the determination of opiate dependency prior to any admission to MAT.
The Physician will meet with all patients prior to admission and assess each individual's opioid dependency.
The determination of dependency will be completed and signed by the Physician prior to admission and placed in the patient medical record.
The Physician is responsible for this requirement and the company's quality assurance process will be utilized to monitor all intake processes through chart reviews.
The company is in the process of upgrading to a higher level of computer software for electronic documentation. The software will help maintain medical compliance and quality assurance.
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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 patient records, the facility failed to document that each patient was provided an average of 2.5 hours of psychotherapy per month during the patient's first 2 years in two of five patient records. The findings include:Thirteen patient records were reviewed on March 10, 2015. Five patient records were reviewed for psychotherapy hours during the first year of treatment. Patient records # 1 and 2 failed to have the average of 2.5 hours of psychotherapy per month during their first 2 years of treatment.Patient # 1 was admitted October 8, 2014 The average psychotherapy hours were reviewed for the months of December, 2014 and January and February, 2015. The patient had an 0 hours documented or December 2014, 2.5 hours documented for January and 2.75 hours documented for February, 2015 for a three month average of 1.75 hours. Patient # 2 was admitted November 12, 2014 The average psychotherapy hours were reviewed for the months of December, 2014 and January and February, 2015. The patient had an 2.5 hours documented or December 2014, 1.25 hours documented for January and 1.25 hours documented for February, 2015 for a three month average of 1.66 hours. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to document that each patient was provided an average of 2.5 hours of psychotherapy per month during the patient's first 2 years.
The facility will ensure that all patients receive the required of monthly psychotherapy. Monitoring of ongoing compliance with this regulation will be the responsibility of the Clinical Supervisor through regular record review and weekly clinical supervision.
Facility Director or designee will meet with program staff in treatment team meeting by 4/15/15 and review all regulation requirements related to individualized psychotherapeutic needs.
All clinical staff will create a caseload tracking sheet that will be turned into Clinical Supervisor on a weekly basis.
Clinical Supervisor will utilize caseload tracking sheets and bi-monthly therapeutic compliance reports to monitor adherence by all clinical staff. Results will be reviewed by both Facility Director and Clinical Supervisor.
The company is in the process of upgrading to a higher level of computer software for electronic documentation. The software will help maintain clinical compliance and quality assurance though the use of processes such as date/time stamps.
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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 one of one patient record.The findings include:Thirteen patient records were reviewed on March 10, 2015. One record required documentation of the materials sent to the receiving provider of the transfer. In patient record # 11, there was no documentation of the materials sent to the receiving narcotic treatment program.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility did not verify that required documents were sent to the receiving program during the transfer process.
The facility did not verify that required documents were sent to the receiving program during the transfer process.
The facility will create a form that will comply with 715.20 requiring that specific documentation be submitted to the receiving program. This check list will be completed by the counselor and list the required documents to be sent. This checklist will be added to the clinical record along with copies of the information sent. In addition, the counselor will also secure a copy of the fax confirmation that will also be placed in the clinical record with the faxed documents and the checklist.
The Facility Director is responsible for creating the identified form, Clinical Supervisor is responsible for training the counselors on the new form, providing ongoing oversight to ensure compliance, and check discharged charts for completion of needed documentation.
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709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on an on-site inspection, the facility failed ensure the confidentiality of the client's identity and records. The findings include:During an on-site inspection on March 10, 2015, while in the Medical Director's office, conversations between counselors and patients could be heard through the walls of the offices. At 9:26 AM, counselor #1 could be heard instructing a patient to sign and back date a treatment plan update. This was reviewed with the Clinical Supervisor at the time of the incident. Late morning, a conversation was heard from the office next door between a counselor and a patient discussing the patient's job, etc. These findings were reviewed with Facility Director, Medical Director, Physician's Assistant and the Clinical Supervisor.
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Plan of Correction
The facility failed to ensure the confidentiality of the client's identity and records.
The facility will purchase and install a sound system/white noise machines to be utilized in facility hallways to provide external sound masking clinical sessions.
The facility will research ways to improve noise reduction for office interiors or ways to mitigate office crossing sounds.
Facility Director is responsible for oversight of installation and implementation of these changes.
Facility Director or designee will meet with program staff in treatment team meeting by 4/30/15 and review regulations related to completion of documentation when due and therapeutic ethics.
The company is in the process of upgrading to a higher level of computer software for electronic documentation. The software will help maintain clinical compliance and quality assurance though the use of processes such as date/time stamps.
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