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 August 7,8,9 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Esper Treatment Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on September 26, 2007. .
|
Plan of Correction
|
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
|
Observations
The facility failed to provide specific policy and procedures regarding initial methadone dose that included specific reasons for exceeding 40 mg. dose limit (42 CFR, Part 8). The initial dose may not exceed 30 mgs., however, the physician may order an additional 10 mgs. depending the patients' response. To exceed 40 mgs. the first day, the prescribing physician must document in the patients' record the reasons that "40 milligrams did not suppress" the patient's opiate withdrawal symptoms and the specific symptomatolgy.
|
Plan of Correction
ETC Response:
ETC changed their Policy & Procedure manual to describe the situation in which our physician would exceeded the 40mgs initial maximum dosing. Our manual now reads:
Initial Dosing Procedures:
A) The physician who performs the admission physical exam will be responsible for writing the initial dosing orders.
1. The initial dose will not exceed 30 mgs.
2. The patient will be dosed in 30-minute intervals to allow the dose-response to be effected.
3. The total first day dose will not exceed 40 mgs, unless our admitting physician documents in the patient's record the 40mgs did suppress opioid abstinence symptoms and the specific symptomology.
|
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.
|
Observations
The facility failed to provide the minimal required therapy hours. A review of 17 patient files for psychotherapy hours identified record # 1 patient did not receive minimum requirement of 2.5 hours per month.
|
Plan of Correction
Our Clinical Director and Chief Operating Officer will hold an in-service training on to ensure that our counselors know the importance of all of our patients receive at least their minimum counseling hours The training is to be held on September 3, 2007. To ensure that our patients are receiving at least the minimum counseling hours our Clinical Director will supervises a quarterly audit of 10% of our active files. Our Clinical Director will supervises all her review of files with a focus on patients meeting their at least their minimum hours. |
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.
|
Observations
The facility failed to comply with their policy and procedure for patient termination. Specifically, patient #5 was discharged without a written notice of termination.
|
Plan of Correction
Prior to any action of Involuntary Detox, the Clinical Director will conduct a case consultation with primary counselor and ensure that the Notice of Involuntary Detoxification is complete and has the Clinical Director approval prior to initiating the action. The Clinical Director (CD) will also ensure that the patient is giving his Appeal of Involuntary Detox Form and that the Adjudication of Involuntary Detox Form is in place to take action. Prior to taking actions the CD will ensure that ETC has copies of all forms.
On August 10, 2007 our Chief Operating Officer Held a training for all staff emphasis the critical important and spirit of properly following our Policy & Procedure on §715.21 Involuntary Detoxification.
On August 10, 2007, our Chief Operating Officer (COO) met with the individual staff member that for two years in a row did not make copy for the patient's record of our Involuntary Detoxification paperwork. The important of making copy for the patient's record of our Involuntary Detoxification paperwork was emphasis to staff member by the COO. The staff member is fully aware that without a copy for our record our actions are impossible to review by anyone who would need to conduct a review such as lawyers, State Licensing, Federal Authorities, Accreditation Bodies, etc. Without the ability to review our actions, it serious affects our ability to be accountable. Without the ability to review our actions, it serious affects our ability to be open and transparent. Without the ability to review our actions, it leads to violations of our patient's Rights. The staff member appeared to comprehend the important.
Check of this Plan of Correction started August 9, 2007.
|
715.22(a) LICENSURE Patient grievance procedures
(a) A narcotic treatment program shall develop and utilize a patient grievance procedure.
|
Observations
The facility failed to follow its own policy and procedure for the processing of patient grievances. Specifically, the policy identified the CEO/Director's role in the grievance resolution but in actuality, the Clinical Director had responsibility for the grievance process and resolution, removing the CEO from involvement.
|
Plan of Correction
ETC changed their Policy & Procedure manual to reflect our practice:
¡± 715.22 PATIENT GRIEVANCE PROCEDURES [PA Dept. of Health DDAP Appeal of Involuntary Detoxification] - (Reviewed 07/07)
It is the policy of The Esper Treatment Center, approved by the Governing Body that the Center will utilize our developed Patient Grievance Procedures.
Procedures:
The aggrieved Patient will request to see the Chief Operating Officer at the Consumer Representative¡¦s (receptionist¡¦s) Desk. The Chief Operating Officer will hear the grievance and complete a Complaint /Grievance Form. Upon initiation of the Patient¡¦s Complaint/Grievance Form the Patient has the right to a full and fair opportunity to be heard, to question and confront person or evidence used against them and to have a fair review by Chief Operating Officer.
The Patient may also voice his/her grievance to the Patient Advocacy Group (Members consist of five patients), Chief Operating Officer, Clinical Director, and Counselor. All voiced grievances must be immediately brought to the attention of the Chief Operating Officer. The Chief Operating Officer, upon receipt of a grievance will set up a meeting will the patient and the parties involved. The disposition of this meeting will be document and kept in patient¡¦s file.
If the grievance is against the Chief Operating Officer, a committee consisting of the Chief Executive Officer, Clinical Director and the Lead Counselor, Carol Trohoske will conduct the review of the case. The disposition of this meeting will be document and kept in Patient¡¦s file.
The Esper Treatment Center will not initiate penalties prior to final resolution with the exception that penalties may be initiated against patients who have committed acts of physical violence or who have threatened to committed acts of physical violence in or around The Esper Treatment Center.
STAKEHOLDER GRIEVANCE PROCEDURES ¡V (Revised 7/07)
It the policy, procedure & practice of the Esper Treatment Center that all applicants, patients, and other stakeholders to be encouraged to express and resolve complaints and grievances by all organizational members to become a part of the formal complaint/grievance process. This is encouraged to provide consistency in our approaches and to keep all members of our organization informed of patterns and the nature of our complaint/grievance filed by our applicants, patients, and other stakeholders to be able to address specific programmatic or unresolved issues that may expose ETC to liability.
ETC accomplishes this policy by:
?Ï Instructing all organizational members to write out a formal complaints or grievances on our Complaint/Grievance Form when they hear a complaint or grievance from our applicants, patients other stakeholders. All organizational members have access to these forms at their work stations. Applicants, patients other stakeholders may fill their own Complaint/Grievance Form where they can obtain from strategic located places around the building such as the reception area, waiting room and group room. All Complaint/Grievance Forms are turned into the Complaint/Grievance Form box or the Chief Operating Officer.
?Ï The Chief Operating Officer assigns appropriate staff to investigate the Complaint/Grievance. The Complaint/Grievance is investigated and a resolution is worked out with the applicants, patients other stakeholders and the Esper Team.
?Ï Results of all Complaint/Grievance Forms are brought to our weekly interdisciplinary team meeting held each Thursday.
All Complaint/Grievance Forms are aggregated and shared quarterly with
?Ï Performance & Quality Improvement Team (PQIT) - Our President/Director/ Owner is a member of our PQIT. PQIT Review the aggregated summary and all the Complaint/Grievance Forms and check for patterns and the nature of our complaint/grievance filed by our patients to be able to address specific programmatic or unresolved issues that may expose ETC to liability. PQIT will identify problems and make recommendations for changes to our Advisory Board (AB), our Governing Body.
?Ï Advisory Board (AB) - Our President/Director/ Owner is a member of our AB. CQIT Review the aggregated summary and all the Complaint/Grievance Forms and check for patterns and the nature of our complaint/grievance filed by our patients to be able to address specific programmatic or unresolved issues that mat expose ETC to liability. AB will review PQIT¡¦s recommendations and make changes if necessary.
Grievance issues may include but are not limited to:
?X Denial of Services
?X Appointment changes;
?X Unprofessional conduct by staff;
?X Unsafe conditions;
?X Sexual exploitation;
?X Discrimination;
?X Unsafe accommodations;
?X Violation of ETC Policies, Procedures, & Practices; and
?X Etc.
The Esper Treatment Center enthusiastically encourages all applicants, patients other stakeholders to file a Grievance/Appeal whenever a patient feels they have been wronged by the Center and/or employees. Should any applicants, patients other stakeholders feel they need assistance in filing a Grievance/Appeal they may feel free to ask any employee to help them fill out or write out and file a form for them.
Timeline:
The initial assigned investigator has 48 hours to conduct their investigation and hold a meeting. Should the aggrieved applicants, patients or other stakeholders not like the disposition of the first grievance hearing they may appeal for a review with our President/Director/Owner/CEO to be held within a week. Should the aggrieved applicants, patients or other stakeholders not like the disposition of the President/Director/ Owner/CEO decision they can appeal for an independent review with the Erie County Office of Drug & Alcohol. If not satisfied after Erie County they can get an independent review from the PA Dept. of Health / Division of Program Licensure.
|
715.23(b)(11) LICENSURE Patient records
(b) Each patient file shall include the following information:
(11) Counselor notes regarding patient progress and status.
|
Observations
The facility failed to document in the progress notes issues relating to the treatment plan. In seventeen charts reviewed for compliance, documentation for patients #3,19, and 20 did not identify progress according to the treatment plan. The progress notes documented in patient file #11 were two months late when done or were not done.
|
Plan of Correction
Our Clinical Director and Chief Operating Officer held an in-service training on to ensure that our counselors know the importance of addressing the treatment plan in every session or explanation in the progress note to why the patient and the counselor deviated from the treatment plan. The training was held on September 3, 2007. To ensure that our counselor and patients are addressing the treatment plan our Clinical Director will supervises a quarterly audit of 10% of our active files. Our Clinical Director will supervise all her review of files with a focus on progress with the treatment plan. |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
|
Observations
The facility failed to complete a psychosocial evaluation within the facility timeframe of 30 days. Specifically, the psychosocial evaluation for patient #11 was not completed within 30 days of admission.
|
Plan of Correction
In chart # 11 a new counselor/employee was under the wrong impression that she had more than the 30-days to complete the Comprehensive Treatment Plan. Our Clinical Director reeducated the counselor and reminded all staff in the August 13, 2007 at our Clinical Peer Review Meeting that Comprehensive Treatment Plan is due within 30-days of admission. Our Clinical Director will be responsible for follow-up to ensure all admission shall have a Comprehensive Treatment Plan within 30-days of admission. She will check this is being done through our 30-day Admission List. |
715.23(d) 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.
|
Observations
The facility failed to provide patients with individualized treatment plans that outlined realistic long and short term goals. The majority of the 17 patient records reviewed for treatment plan content were found to include generalized plans to address the disease of addiction and and did not address the treatment specific issues of the patient.
|
Plan of Correction
In 2006 /2007, Esper Treatment Center started a group for patients who are in denial of their other than opioids drug abuse. These groups are designed to give our patient in this category basic Drug & Alcohol abuse/dependency information to aide the patient in their denial. Our Clinical Director designed a standardizes treatment plan to address this group. In the cases of majority of the 17 patient records their counselors did not identify or address on initial comprehensive treatment plan any other problem area to address while the patients were going to the group.
On August 13, 2007 our Clinical Director redesigned all standardized group plan to include a place for an individual problem area to be addressed while the patient is going through groups. On August 13, 2007 at our Clinical Peer Review Meeting, our Clinical Director informed the staff that they are require to address an individual problem in conjunction with the group plan and informed the counselors that she would not sign off on a group plan if there is not an individual problem being address.
|
715.23(d)(1) 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.
(1) The treatment plan shall identify the behavioral tasks a patient shall perform to complete each short-term goal.
|
Observations
The facility failed to provide treatment planning that identified short term goals with specific time fames and tasks. The majority of the treatment plans reviewed displayed short term goals that were generically prepared and lacked timeframes for completion.
|
Plan of Correction
Quarterly throughout the year our Clinical Director will conduct Treatment Plan Trainings to improve on our staff to develop and carryout a treatment plan in an efficient manner. Follow-up by our Clinical Director will occur in individual staffings and in our Weekly Clinical Peer Review Meeting. Supervisory Follow Up will occur as our Clinical Director reviews for signature all treatment plans. The Clinical Director will conduct individual treatment plan trainings as she does not approve of a treatment plan and works with the counselor to come up with an approved treatment plan. The Clinical Director will develop a new Treatment Plan that includes timeframes for all goals and action steps. |