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 3 through 5, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Lebanon Treatment 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 May 29, 2010.
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Plan of Correction
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of time sheets, census reports and an interview with the facility director, the facility failed to provide at least one hour of physician time per week on site for every ten patients.
The findings include:
On May 3 through 5, 2010 census reports and physician and the physician extender's work schedules were reviewed for the months of December, 2009 through May, 2010.
During the week of February 28 to March 6, 2010 the census was 187 patients and 15.5 physician hours. The facility needed physician hours totaling 18.7 hours during this timeframe.
During the week of March 7 to March 13, 2010, the census was 189 patients and 18.5 physician hours. The facility needed physician hours totaling 18.9 hours during this timeframe.
During the week of March 14 to March 20, 2010 the census was 193 patients and 18.5 hours. The facility needed physician hours totaling 19.3 hours during this timeframe.
During the week of March 21 to March 27, 2010 the census was 193 patients and 17 physician hours. The facility needed physician hours totaling 19.3 hours during this timeframe.
During the week of March 28-April 3, 2010 the census was 194 patients and 18.5 physician hours. The facility needed physician hours totaling 19.4 hours during this timeframe.
During the week of April 4 to April April 10, 2010 the census was 200 patients and 18.5 physician hours. The facility needed physician hours totaling 20 hours during this timeframe.
During the week of April 11 to April 17, 2010 the census was 203 patients and 18.5 physician hours. The facility needed physician hours totaling 20.3 hours during this timeframe.
During the week of April 18 to to April 24, 2010 the census was 205 patients and 18.5 physician hours. The facility needed physician hours totaling 20.5 hours during this timeframe.
During the week of April 24 to May 1, 2010 the census was 206 patients and 18.5 physician hours. The facility needed physician hours totaling 20.6 hours during this timeframe.
A discussion was held with the facility director May 4 and May 5, 2010 confirming that there were insufficient physician hours during February 28, 2010 through May 1, 2010.
This is a repeat citation.
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Plan of Correction
Plan of Correction:
In accordance to this standard an additional 2.5 hours has been added to the current doctor hour's schedule. The additional hours will ensure that the facility is in compliance regarding this standard. Nursing Supervisor will ensure that this standard continues to be in compliance on an on-going basis.
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715.13(a) LICENSURE Patient identification
(a) A narcotic treatment program shall use a system for patient identification for the purpose of verifying the correct identity of a patient prior to administration of an agent.
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Observations
Based on a review of the facility's policies and procedures and observation during a tour of the dispensing area, the facility failed to ensure that a patient had removed clothing from their head and face for the purpose of verifying correct identity
The findings include:
A tour of the dispensing area was conducted on May 4, 2010 between 9:30 and 10:15 AM. Patients were observed by this reviewer as they waited at the dispensing window while the dispensing nurse prepared the dose of a narcotic agent. The dispensing nurse failed to ask the patient to remove clothing that partially covered his face as part of the protocol to verify the patient's identity prior to dosing. In accordance with facility policy and procedure, patients are not to present for dosing in clothing that covers the face.
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Plan of Correction
In accordance to this standard all dispensing nursing staff will be re-trained on the policy regarding head gear and the identification of patients. This training will be conducted by the Nursing Supervisor and Nursing Supervisor will ensure that this policy is being adhered to on an on-going 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 and a discussion with the facility director and clinical supervisor, the facility failed to provide each patient with the minimal requirement of an average of 2.5 hours of psychotherapy per month during the patient's first 2 years of treatment in one of seven records.
The findings include:
Eight patient records were reviewed on May 4 through May 5, 2010. Seven of eight records were reviewed for 2.5 hours of psychotherapy hours per month.
Patient record #7 was admitted on May 6, 2009 and transferred to another methadone facility on January 21, 2010. From November 24, 2009 until January 21, 2010 there was no documentation of any psychotherapy hours in the patient record.
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Plan of Correction
The requirements of treatment will be reviewed with staff particularly regarding the expectations of counseling hours. This will be addressed at the clinical team meeting on 5/20/2010. The minimum 2.5 hour requirement will be reviewed along with the expectation of individualized treatment with clinical time individually and clinically based. Charts will be audited for compliance, as well as the utilization of the clinical hours stats form at the end of the month which displays the direct clinical services.
Clinical Supervisor will ensure compliance with this standard on an on-going basis.
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