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 April 9 and 10, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Summit Medical Services 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 May 5, 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 the counselor caseloads, the facility failed to provide caseloads of less than 35 patients to one counselor. A conversation with the director revealed a counselor resigned on April 4, 2008. This counselor's caseload has been divided between the other staff members. Five of seven counselors have caseloads that exceed the 35 to 1 patient to counselor ratio, employees number # 1, 3, 4, 5, and 7.
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Plan of Correction
The counselor that resigned had her last day on 4/7. Ian Winter, Facility Director, advertised the position upon learning of her resignation. Upon the licensure visit, SMS was still in the hiring process.
Facility director did hire a full-time counselor to fill this position, thus bringing counselor/patient ratios into compliance once again. |
715.9(a)(2) 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:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on the patient record review, the facility failed to provide emergency contacts in three of six records reviewed, specifically records # 4, 5, and 10.
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Plan of Correction
Prior to licensure visit on 4/9,10/08, SMS addressed obtaining the emergency contact as recommended, but also respected the rights of confidentiality of patients to refuse signing an emergency consent.
SMS facility director, Ian Winter, has since implemented procedure that staff conducting an intake strongly recommend a patient sign an emergency contact and lists the reasons why. If the emergency consent is still not collected at this time, the counselor assigned to that particular patient will ensure that one is completed after a rapport is built, within 30 days of assignment. |
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 the patient record review, the facility failed to follow its policy and provide written notification to the patient of the involuntary discharge. This was found in two of two applicable records, records # 4 and 15.
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Plan of Correction
Prior to 4/9,10/08 licensure review, it was noted SMS was not consistent in following written notification to the patients regarding involuntary discharges.
This plan was ammended by Ian Winter, Facility Director. Once the course of action by SMS becomes an involuntary discharge, a written notice of detoxification will be given to the patient. Once recieved, the patient will have the opportunity to indicate the intention to follow up with the SMS appeals process or not, and the chosen course of treatment will ensue as indicated by the patient. |