INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use narcotic agents, specifically methadone and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on October 13-15, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Aldie Counseling Center 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 November 13, 2010.
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Plan of Correction
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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 three of three patient records.
The findings include:
Twenty-one patient records were reviewed on October 13-15, 2010. Three patient records required documentation of the materials sent to the receiving provider of the transfer. In patient records # 15, 16 and 17 there was no documentation of the materials sent to the narcotic treatment program.
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Plan of Correction
A form that had been previously used, but was not currently being used to document materials that were sent, has been revised and updated by the NTP Coordinator. On 11/18/2010 the program staff will be instructed by the Program Coordinator on the required use of this form whenever they are transferring a client to another narcotic treatment program. In order to monitor compliance, when the Program Coordinator is conducting the documentation review of any client record being closed, the Coordinator will confirm that this form has been properly completed for each person who is transferred to another NTP. |
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 the review of patient records, the facility failed to restrict the reasons for involuntary termination to those reasons allowed by regulation in three of four patient records.
The findings include:
Twenty one patient records were reviewed October 13-15, 2010. Four patient records were reviewed for involuntary, or therapeutic, discharge. Three patient records contained documentation of the patient being discharged for reasons other than those listed by regulation.
Patient # 9 was admitted September 3, 2008. The patient was discharged as non-compliant February 5, 2010. The patient was discharged for inconsistent attendance and failure to follow the treatment plan. However, the patient had not missed three consecutive days or longer nor had there been recent documented attempts to engage the patient in treatment through treatment planning or current behavioral contracts.
Patient # 18 was admitted February 2, 2010. The patient was discharged for not engaging into the treatment experience. The patient was transferred to the facility after being inducted into maintenance at a residential program as she was in her third trimester of pregnancy. While the patient came in to dose most days, she did not miss three consecutive dosing days. This was the patient's first treatment experience. The patient's psychosocial history and evaluation clearly stated the patient had no family support and a history of abuse and trauma in the family, yet there was no documentation of any attempts to engage the patient in the treatment process. The patient was given a contract to make every session and give urine drugs screens free of illicit substances March 16, 2010 to April 16, 2010. There was documentation of the patient giving birth, but it was not clear when that occurred. The patient requested another chance since she had had the baby and was able to access transportation. This was attached to the contract. There was no documentation of a response to this letter.
Patient # 19 was admitted August 27, 2007. The patient was given notice of intent to terminate on September 15, 2010 for "inconsistent attendance" and "inconsistent payments of the co-pay". The patient and counselor developed treatment plans on July 14 and September 16, 2010 that discussed patient's finances needing to be budgeted, but there was nothing specific regarding the patient paying her co-pay.
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Plan of Correction
The Program Coordinator will provide additional staff training on State Regulations and Aldie's policy/procedure regarding the allowable reasons for involuntary terminations; written copies of these items will be provided as part of a specific training.
All clients at risk of being terminated from the Pharmacotherapy program will be reviewed at the Treatment Team Meeting as a case consult to determine what additional efforts could be implemented in an attempt to retain the client in treatment prior to the Team's final termination decision. Case consults addressing involuntary termination will clearly identify only areas allowed by regulations and policies prior to the Program Coordinators signature. Documentation of the reason for the termination, such as the Notice to Terminate given to the client, will specify the reason which is allowable according to the applicable regulation.
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on the review of patient records, the facility failed to complete annual evaluations in accordance with the regulations in five of seven patient records reviewed.
The findings included:
Twenty one patient records were reviewed October 13-15, 2010. Seven of these patient records required documentation of an annual clinical review. Five of the seven did not contain documentation of an annual evaluation that was required to be completed within the past year..
Patient # 2 was admitted August 18, 2007. The last annual evaluation was dated August 27, 2009. There was no evaluation done for 2010.
Patient # 6 was admitted April 21, 2007. There was no annual evaluation, due April 2010.
Patient # 7 was admitted April 28, 2007. There was no annual evaluation, due April 2010.
Patient # 15 was admitted May 21, 2010. There was no annual evaluation, due May 2010.
Patient # 19 was admitted August 23, 2007. The last annual evaluation was documented September 2, 2009. There was no evaluation completed for 2010.
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Plan of Correction
A 'Caseload Spreadsheet' has been developed and given to all clinicians to help clinicians track client anniversary date, annual evaluation date, date of last treatment plan and case consult and other important issues relevant to the Pharmaco program. This spreadsheet will be reviewed by the Program Coordinator and the Clinician during Individual Supervision on, at least, a monthly basis to insure compliance. The Program Coordinator will provide further training to all clinicians on protocols in place to maintain compliance with each client receiving an annual evaluation by their counselor. Completion date will be December 15, 2010. |