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 May 1-2, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pa Associates, LLC D/b/a Mount Pocono Medical 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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715.8(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 and discussion with facility staff, the facility failed to maintain counselor caseloads to no more than 35 to 1.
The findings include:
Administrative documentation that included counselor caseloads was reviewed and discussed with staff on May 1, 2012. One part time (average 25 hours) counselor had a case load of 31 patients at the time of the inspection, which is a full time equivalent (FTE) caseload calculated at 50:1.
This is a repeat citation from the complaint investigation dated January 4, 2012.
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Plan of Correction
The facility did not comply with the regulation requiring that a FTE maintain a caseload ratio of no more than 35:1. It is the responsibility of the facility to insure that all counseling FTE's fall within the required ratio limits. In this case the part time counselor exceeded the allowable ration. The Facility Director will increase the work hours for any part time employee that assumes additional counseling responsibilities to insure that the allowable ratio is maintained. The Facility Director will be responsible for monitoring compliance in this area. |
715.9(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
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Observations
Based on the review of patient records, the facility failed to contact the previous narcotic treatment facility for the patient's treatment history in one of one patient record reviewed.
The findings include:
Ten patient records were reviewed May 1-2, 2012. One patient record indicated a prior history of narcotic treatment that required contact with the prior narcotic treatment facility for the previous treatment history the patient reported to have received.
Patient record # 7 contained documentation that the patient had received narcotic treatment services previously at another narcotic treatment program. There was no documentation indicating the facility made any attempt to obtain the patient's previous treatment history from the identified narcotic treatment program.
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Plan of Correction
The facility did not comply with regulation 715.9 (c) stating that the facility would contact previous treatment centers with the patients consent for the purpose of gathering information on the patient's treatment history. All staff will be trained in this area beginning on June 5, 2012 and ongoing supervision and oversight will be provided by the Facility Director and Senior Counselor/Clinical Supervisor on a monthly basis. |
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 a review of patient records, the facility failed to provide each patient an average of 2.5 hours of psychotherapy per month during the patient's first two years of treatment in four of six patient records.
The findings include:
Ten patient records were reviewed May 1-2, 2012. Six patient records were reviewed for psychotherapy hours during the first two years of treatment.
Patient # 1 was admitted May 13, 2011 and required at least 2.5 hours of psychotherapy per month. The months of February, March and April were reviewed for compliance of therapy hours. There were no hours of therapy in February 2012, one hour of therapy documented in March and one half hour of therapy in April 2012. The patient's dosing records were reviewed and the patient dosed on a daily basis for those months except for two absent days in March 2012.
Patient # 6 was admitted January 5, 2011 and required at least 2.5 hours of psychotherapy per month. The months of February, March and April were reviewed for compliance of therapy hours. There was 1.5 hours of therapy in February 2012 and 1.5 hours of therapy documented in March.
Patient # 7 was admitted February 3, 2012 and required at least 2.5 hours of psychotherapy per month. The months of February, March and April were reviewed for compliance of therapy hours. There was one hour of therapy in February 2012, no therapy documented in March and three quarters of an hour of therapy in April 2012.
Patient # 8 was admitted January 13, 2012 and required at least 2.5 hours of psychotherapy per month. The months of February, March and April were reviewed for compliance of therapy hours. The average of the three months of therapy combined was only two hours.
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Plan of Correction
The facility failed to comply with regulation 715.19 (1) stating that a minimum of 2.5 hours per month of psychotherapy will be provided to the patient. The facility will provide one training and education session to all staff on June 5, 2010. Ongoing oversight, training, and supervision will be provided by the Senior Counselor/Clinical Supervisor and the Facility Director. |
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 three patient records.
The findings include:
Ten patient records were reviewed May 1-2, 2012. Three 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, or failed to list the reasons for the discharge.
The findings include:
Patient # 4 was discharged April 27, 2012 for non-compliance. The notice provided to the patient did not include the specific non-compliance by the patient. Further documentation reviewed indicated the patient was discharged for financial reasons. The documentation further revealed the facility failed to develop a treatment plan that would guide the patient to come into compliance financially.
Patient # 9 was discharged April 3, 2012 for non-compliance. There was no documentation as to the specific non-compliance perpetrated by the patient.
Patient # 10 was discharged April 24, 2012 for non-compliance. There was no documentation as to the specific non-compliance perpetrated by the patient.
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Plan of Correction
The facility did not comply with regulation 715.21. On June 12, 2012 the facility will provide one education and training session to staff to insure that they understand the regulation regarding appropriate discharge and documentation. Ongoing monthly oversight and supervision will be provided by the facility director and/or the senior counselor/clinical supervisor. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on a review of patient records, the facility failed to document all of the required information in four of four patient records.
The findings include:
Ten patient records were reviewed May 1-2, 2012. Four patient records were reviewed for complete discharge summaries.
Patient # 3 was discharged January 20, 2012. The form used for the discharge summary has no place for the reason for treatment to be documented and no documentation of the services offered. This information was not included anywhere in the discharge summary.
Patient # 4 was discharged April 27, 2012. The form used for the discharge summary has no place for the reason for treatment to be documented and no documentation of the services offered. This information was not included anywhere in the discharge summary.
Patient # 9 was discharged April 3, 2012. The form used for the discharge summary has no place for the reason for treatment to be documented and no documentation of the services offered. This information was not included anywhere in the discharge summary.
Patient # 10 was discharged April 24, 2012. The form used for the discharge summary has no place for the reason for treatment to be documented and no documentation of the services offered. This information was not included anywhere in the discharge summary.
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Plan of Correction
The facility did not comply with regulation 715.23. MPM established a new Discharge Summary on June 1, 2012 that includes the reason for treatment, services offered, and services rendered. On June 7, 2012 the facility will provide one education and training session to staff. Ongoing oversight and supervision will be provided by the facility director and/or the senior counselor/clinical supervisor to insure compliance. |
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 three of three patient records reviewed.
The findings included:
Ten patient records were reviewed May 1-2, 2012. Three patient records required documentation of an annual clinical review.
Patient # 5 was admitted January 5, 2011 and required an annual evaluation January 5, 2012. There was no documentation an annual evaluation was completed and reviewed by the medical director.
Patient # 9 was admitted August 11, 2010 and required an annual evaluation August 11, 2011. There was no documentation an annual evaluation was completed and reviewed by the medical director.
Patient # 10 was admitted August 18, 2010 and required an annual evaluation August 18, 2011. There was no documentation an annual evaluation was completed and reviewed by the medical director.
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Plan of Correction
The facility did not comply with regulation 715.23. On June 14, 2012 MPM will provide one education and training session to all clinical staff on completing the Annual Review form. Education will include conducting an annual review with the patient on their progress in treatment, areas of difficulty, and goals for the upcoming year. Counselors will be instructed to incorporate the patient's continued areas of difficulty and goals for the upcoming year into the comprehensive treatment plan. Ongoing oversight and supervision will be provided on a monthly basis by the facility director and/or senior counselor/clinical supervisor to insure compliance. |
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 patient records, the facility failed to document the progress or lack of progress in achieving the goal statements from the prior treatment plan in patient records.
The findings include:
Ten patient records were reviewed May 1-2, 2012. Five patient records were reviewed for treatment plan update documentation.
Patient # 1 was admitted May 13, 2011. While treatment plans were updated, goals were dropped or added without documentation for the purpose. Goal progress was was not documented.
Patient # 2 was admitted September 8, 2011. The last treatment plan update was dated February 8, 2012.
Patient # 3 was admitted July 28, 2010. The patient was discharged as deceased January 20, 2012. The last treatment plan update was documented October 27, 2011. Another update was to have been done by December 27, 2011.
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Plan of Correction
The facility did not comply with regulation 715.23. On June 19,2012 MPM will provide one education and training session to clinical staff on establishing short term goals, long term goals, and objectives that are specific, measurable, achievable, realistic, and time limited. Ongoing education, training, and oversight will be provided by the facility director and/or senior counselor during individual and group supervision. |