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 10-12, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center for Behavioral Health-HA, Inc 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 patient records and interviews with the facility director and clinical supervisors, the facility failed to ensure that the counseling caseload for one FTE counselor in an outpatient narcotic treatment program did not exceed 35 active patients.
The findings include:
The counselor to patient caseload ratios were reviewed on May 10-12, 2011. The facility failed to maintain a counseling caseload for one FTE counselor in an outpatient narcotic treatment program which did not exceed 35 active patients in counselor record #1
The caseload ratio for counselor #1 was 36:1.
An interview with the facility director and clinical supervisors on May 12, 2011 confirmed the counselor's caseload ratio was 36:1.
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Plan of Correction
Waivered caseloads ratios will be figured out with the formula provided by the auditor. This ratio will be monitored by the Program Director and the Clinical Supervisors.
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715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of patient records, an interviews with the facility director and clinical supervisors, the facility failed to ensure that the patient was initially dosed following the completion of a drug-screen urinalysis in two of eight patient records.
The findings included:
Thirty six patient records were reviewed on May 10-12, 2011. Eight patient records were reviewed for the completion of a drug-screen urinalysis prior to a patient's initial dose. The facility failed to document the completion of a drug screen urinalysis prior to dosing in patient records # 22 and 24.
Patient # 22 was admitted into treatment on February 2, 2011. Patient # 22 received a dose of 30 mg on February 2, 2011, the same date that the patient had submitted a urine specimen for a drug-screen urinalysis. The results of the urine specimen for the drug-screen urinalysis were received on February 3, 2011.
Patient # 24 was admitted into treatment on October 12, 2010. Patient # 24 received a dose of 30 mg on October 12, 2010, the same date that the patient had submitted a urine specimen for a drug-screen urinalysis. The results of the urine specimen for the drug-screen urinalysis were received on October 13, 2010.
The facility director and clinical supervisors were interviewed on May 12, 2011 and confirmed the patients referenced above had received their initial dose prior to the completion of a drug screen urinalysis.
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Plan of Correction
All Patients entering the program will provide an initial drug screen urinalysis. Results will be obtained before patient receives their initial dose of methadone. This will be monitored by the Program Director.
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715.16(a)(5) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(5) A narcotic treatment program shall develop written policies and procedures relating to granting and rescinding take-home medication privileges.
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Observations
Based on the review of the policy and procedures manual, patient records and an interview with the facility director, the facility failed to document written policies and procedures relating to granting take-home medication privileges.
The finding include:
Thirty six patient records were reviewed on May 10-12, 2011. Twelve patient records were reviewed for take home medication privileges. The facility did not document policies or procedures for the securing of take home medications when a patient has terminated treatment.
Patient # 18 was admitted on January 23, 2003 and discharged on March 24, 2011. On March 22, 2011, the patient received 6 take home medication bottles as he was on a one day per week dosing schedule. The patient contacted the facility, via a phone call, on March 24, 2011. The patient reported that he had found a suboxone doctor and that he would begin taking the suboxone in 48 hours. There was no documentation that specified what happened to the take home medication. Additionally, there was no documentation of a policy or procedure to be followed in a situation in which a patient's treatment is terminated and there remains unused medication to be accounted for.
An interview with the facility director on May 12, 2011 confirmed that there was no policy or procedure addressing this situation. The facility director also confirmed that there was no documentation that the patient was instructed to return the remaining take home bottles to the facility, nor was there documentation that the remaining take home bottles had been returned to the facility.
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Plan of Correction
If a patient calls stating they wish to leave the program to enter another treatment and still have take home bottles they will be instructed to bring back any unused bottles to the clinic for destruction. This will be monitored by the Program Director and the Clinical Supervisors.
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709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on observation and an interviews with the nurses and the facility director, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one patient record.
The finding include:
Patient dosing was observed on May 12, 2011 from 7:55 AM to 8:30 AM. During this observation, patient # 36, admitted on May 12, 2011, presented at the dosing window. At that time, the dosing nurse informed the patient there were consent forms to be signed. The forms included the patient's consent for blood testing, a urinalysis and HIV testing information. The dosing nurse had briefly summarized the content of the consents to the patient and then informed the patient to electronically sign the consents by signing the signature pad. The consents were not presented to the patient for review prior to the patient being requested to sign. After the patient signed the consent, the patient was asked if they wished to receive a copy. This patient verbally declined. The patient was not provided the opportunity to review the consents in their entirety prior to requesting the patient's signature. The facility did not obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
An interview with the nurses on May 12, 2011 confirmed that the patient was not provided the consents prior to requesting the patient's signature. The consents are summarized for the patient. The patient is offered a copy once the signature has been documented. This is the current practice of the facility.
An interview with the facility director on May 12, 2011 confirmed the facility's current practice.
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Plan of Correction
The Blood/Urine Testing and HIV Information and Notification Consent forms, will be given to the patient in hard copy form to read before signing the signature pad on the computer the patient will be then given the signed forms. This will be monitored by the Nurse Manager and the Program Director. |