INITIAL COMMENTS
|
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 June 21 - 22, 2010 by staff from 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 compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and a plan of correction is due on July 12, 2010.
|
Plan of Correction
|
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.
|
Observations
Based on a review of active patient case lists, the narcotic treatment program monitoring questionnaire, and an interview with the clinical supervisor, the facility failed to maintain one FTE (full time equivalency) counselor for every 35 active patients, as required.The findings include:On June 21 - 22, 2010, the narcotic treatment program monitoring questionnaire and active patient case lists were reviewed. Per regulation, the counseling caseload for one FTE counselor in an outpatient narcotic treatment program may not exceed 35 active patients. The current census of the facility is 500 patients. There are 427 active patients who are assigned to counselor caseloads. The facility has 73 active patient records that are not assigned to a counselor who is currently working at the facility. One counselor is on military leave and has 38 active patients assigned to her caseload. A second counselor is on extended medical leave and has 35 active patients assigned to her caseload. The facility failed to maintain one FTE counselor for every thirty-five active patients.On June 21, 2010, the clinical supervisor was interviewed. The clinical supervisor confirmed that the facility has 73 active patients that are not assigned to a counselor who is currently working at the facility. The clinical supervisor reported that the counselor who is on military leave is due back to work in the near future. The facility is also planning to hire a new counselor as soon as possible.
|
Plan of Correction
The facility did not operate within regulation requiring one FTE for every 35 patients.
The facilty will take action to fill any FTE on extended leave with temporary counselors through recruitment. Recruitment efforts will be made by advertising in the newspaper, information provided to local university graduate schools, and through the internet. These actions will be taken promptly upon being notified of any FTE extended leave.
In the event that we are not able to promptly fill the vacancy we will temporarily assign cases to existing FTE's
The Facility Director is responsible for implementation and overall management of this process. |
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.
|
Observations
Based on a review of patient records and an interview with the clinical supervisor and lead counselor, the facility failed to document what materials were sent to the receiving narcotic treatment program, as required.The findings include:Twenty-one patient records were reviewed on June 21 - 22, 2010. Three records pertained to patients that had requested a transfer to another narcotic treatment program. Per regulation, the transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program. The facility failed to document what materials were sent to the receiving narcotic treatment program in patient records # 9 and 17.Patient # 9 was admitted on October 15, 2009 and transferred to another narcotic treatment program on October 30, 2009. There was no documentation of what materials were sent to the receiving narcotic treatment program. Patient # 17 was admitted on July 13, 2001 and transferred to another narcotic treatment program on November 12, 2009. There was no documentation of what materials were sent to the receiving narcotic treatment program. On June 22, 2010, the clinical supervisor and lead counselor were interviewed regarding these patient records. The lead counselor reviewed patient records # 9 and 17 and confirmed there was no documentation of what materials were sent to the receiving narcotic treatment program.
|
Plan of Correction
The facility did not verify that required documents were sent to the recieving 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 recieving 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 Clinical supervisor is responsible for creating the identified form, trainining the counselors in its completion, and providing ongoing oversite to ensure compliance. The Facility Director will oversee the Supervisor as a second means of maintaining compliance. |