INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted on January 4, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site complaint investigation, PA Associates, LLC d/b/a MT. Pocono Medical 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 investigation.
|
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 the review of administrative documentation, 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 on January 4, 2012. Counselors # 1, 4 and 5 had caseloads of 36:1. Counselor # 3 had a caseload of 38:1.
The findings were reviewed with the facility director.
|
Plan of Correction
In order to maintain the client/counselor 35:1 ratio, the Facility Director along with the Senior Counselor will track census and staff composition. Additional staff will be hired as necessary in order to alleviate any increases in FTE caseloads. Should an unexpected overage occur the Facility Director will ensure that there will be an admission freeze until we are fully staffed and/or the implementation of the appropriate overtime hours utilizing the state formula to meet client/counselor ratios to comply with state regulations. |
715.16(c)(3)(i-viii) LICENSURE Take-home privileges
(c) A narcotic treatment program shall require a patient to come to the narcotic treatment program for observation daily or at least 6 days a week for comprehensive maintenance treatment, unless a patient is permitted to receive take-home medication as follows:
(3) A narcotic treatment program may permit a patient to reduce attendance at the narcotic treatment program for observation to one time weekly and receive no more than a 6-day take-home supply of medication when in the reasonable clinical judgment of the narcotic treatment physician, which is documented in the patient record:
(i) A patient demonstrates satisfactory adherence to narcotic treatment program rules for at least 3 years.
(ii) A patient demonstrates substantial progress in rehabilitation.
(iii) A patient demonstrates responsibility in handling narcotic drugs.
(iv) A patient demonstrates that rehabilitation progress would improve by decreasing the frequency of attendance for observation.
(v) A patient demonstrates no major behavioral problems.
(vi) A patient is employed, is actively seeking employment, attends school, is a homemaker or is considered unemployable for mental or physical reasons.
(vii) A patient is not known to have abused alcohol or other drugs within the previous year.
(viii) A patient is not known to have engaged in any criminal activity within the previous year.
|
Observations
Based on a review of patient records, the facility failed to consider the criteria for granting a 6-day take-home supply of medication in one of one patient record.
The findings include:
Six patient records were reviewed on January 4, 2012. One patient record was reviewed for a 6 day take-home supply of medication. The facility failed to consider the criteria for granting a 6-day take-home supply of medication in patient record # 4.
Patient # 4 was admitted as a transfer from another narcotic treatment program with documentation of continuos narcotic program treatment from November 24, 2009. The patient attended relapse group on 12/9/2011 and 12/21/2011 and reported that he "took Percocet by accident." The patient was granted privileges for a 6 day take-home supply of medication on 12/27/2011. The facility failed to document consideration given to the determination of a six day take-home schedule for patient # 4 following the admitted use of Percocet.
|
Plan of Correction
The facility failed to consider the criteria for six day take homes. The program physician should determine and document the appropriateness of all take home doses, utilizing the state/federal criteria. All issues in the criteria should be presented to the physician, with input from other medical and counseling staff as appropriate. It is the responsibility of the Senior Counselor to ensure that this process is consistently managed and documented according to regulation. The Facility Director is responsible to provide ongoing oversight in this area. |
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
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 2 years of treatment in 3 of 6 records.
The findings include:
Six patient records were reviewed on January 4, 2012. Three patient records were reviewed for psychotherapy hours during the first two years of treatment. Patient records # 1, 4, and 6 failed to have the average of 2.5 hours of psychotherapy per month during their first 2 years of treatment.
Patient # 1 was admitted April 26, 2010. The psychotherapy hours were reviewed from July 2011 to December 2011. The patient averaged 2.17 hours of psychotherapy for the six months reviewed.
Patient # 4 was admitted as a transfer with continuous treatment begun November 24, 2009. The psychotherapy hours were reviewed from July 2011 to December 2011. The patient averaged 1.92 hours of psychotherapy for the six months reviewed.
Patient # 6 was admitted April 14, 2010. The psychotherapy hours were reviewed from July 2011 to December 2011. The patient averaged 1.5 hours of psychotherapy for the six months reviewed.
|
Plan of Correction
It is the responsiblity of the Facilty to make sure the Patient receives the appopriate amount of service. It is the responsibility of the counselor to see that those service hours are met for each of the patients on their caseload. The Senior Counselor is to provide ongoing supervision to ensure that these services are met in a timely manner. The Facility Director will provide additional supervision and training as needed. The Senior Counselor will regularly review patient cases/charts to make sure we are meeting the state regulations.
Facility Director and Senior Counselor will be responsible to review this on a weekly basis to ensure that services do not get behind. |
715.22(b) LICENSURE Patient grievance procedures
(b) The procedure shall permit aggrieved patients a full and fair opportunity to be heard, to question and confront persons and evidence used against them and to have a fair review of their grievances by the narcotic treatment program director. If the grievance is filed against the narcotic treatment program director, the review of the case shall be conducted by either a multi-representative group of the narcotic treatment program or a subcommittee of the governing body instituted for the express purposes of grievance adjudication.
|
Observations
Based on the review of administrative documentation, the facility failed to document a full and fair review of the patients' grievances in 4 of 5 grievances.
The findings include:
Administrative documentation that included grievance hearing documentation was reviewed on January 4, 2012. Three patients filed a total of five grievances from January to December 2011. Four of the five grievances were filed against staff members.
A patient grievance was filed on 3/2/2011 against staff member # 1. Documentation regarding the grievance resolution specified that staff member # 1 participated in the grievance review and assisted in the determination of the grievance outcome.
A patient filed two grievances on 5/3/2011 against the staff members 1 and 2. A grievance hearing committee note was documented on 5/5/2011. The committee included the signatures of the facility director, staff nurse, front desk staff and staff memeber #2 listed in the identified in the grievance.
.
A patient grievance was filed on 6/6/2011 against staff person #1. According to facility documentation, the grievance was reviewed by staff person # 1 and the facility director.
|
Plan of Correction
The facility was found to have not followed the grievance process fully.
The facility has a grievance policy that addresses how it should be executed. It is as follows:
a. Patient submits grievance to counselor in person for discussion/resolution.
b. If patient is not satisfied with counselor's resolution, he/she submits grievance in writing to Project Director and/or Facility Director within twenty-four hours of notification of counselor's decision.
c. Project Director and/or Facility Director notifies Grievance Committee (CEO, Project Director, Supervising Counselor, Physician, Nurse) within twenty-four hours of receipt of formal grievance.
d. Project Director and/or Facility Director schedule Grievance Hearing within five working days; notifies all members, patient, primary counselor.
e. Grievance Hearing occurs. Information can be presented by patient and primary counselor and other relevant staff.
f. Project Director and/or Facility Director notifies patient of Grievance Committee decision in writing within twenty-four hours of decision. The committee's decision will be upheld and considered final.
It is the Facility Directors responsibility to ensure that is process if followed and sign off on each one when completed.
|
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).
|
Observations
Based on a review of patient records, the facility failed to document a progress or lack of progress in achieving the goal statements from the prior treatment plan in patient records.
The findings include:
Six patient records were reviewed on January 4, 2012. Five patient records were reviewed for treatment plan documentation. Four of the five records did not document an update of the treatment plan as required every 60 days.
Patient # 2 was admitted on April 6, 2010. A treatment plan update was documented on 10/15/2011. The next treatment plan update was due on 12/15/2011. There was no documentation in the patient record that identified the treatment plan had been updated.
Patient # 3 was admitted on April 27, 2010. A treatment plan update was documented on 10/27/2011. The next treatment plan update was due on 12/27/2011. There was no documentation in the patient record that identified the treatment plan had been updated.
Patient # 4 was admitted on April 21, 2010. A treatment plan update was documented on 10/25/2011. The next treatment plan update was due on 12/25/2011. There was no documentation in the patient record that identified the treatment plan had been updated.
Patient # 6 was admitted on April 12, 2010. A treatment plan update was documented on 8/17/2011. The next treatment plan update was due on 10/17/2011 with another due on 12/17/2011. There was no documentation in the patient record that identified the treatment plan had been updated.
|
Plan of Correction
The new process to ensure that all services are completed is as follows. All charts that are worked on for that day are to be turned into the Senior Counselor for review. Treatment plans will be verified and entered into the tracker by the Senior Counselor to ensure that treatment plans are being updated every two months. The Facility Director will have access to this information so she can follow up with Senior Counselor that services are being completed in a timely fashion. If services are lacking, the follow up will verify if it is the patient is not attending to the services or if the counselor is not completing the work. At that time action will be taken toward either the patient to update the treatment plan or the counselor for a plan of correction to be put into place. Facility Director and Senior Counselor will be responsible to review this on a weekly basis to ensure that services do not get behind. |