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 June 24, 25 and 26, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Esper Treatment Center, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on July 24, 2008.
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Plan of Correction
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715.10(c) LICENSURE Pregnant patients
(c) Counseling records and other appropriate patients records shall reflect the nature of prenatal support provided by the narcotic treatment program.
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Observations
Based on a review of 20 patient records, two were required to have documentation of prenatal support provided to pregnant patients. The facility failed to ensure that pregnant patients' records reflected the nature of prenatal support provided by the narcotic treatment program in one of two patient records, # 1. Patient # 1 was pregnant when she entered treatment on March 12, 2008; the patient's treatment plan did not address her pregnancy until May 2008.
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Plan of Correction
§715.10 (c) NM081 Pregnant Patients
To ensure this does not occur in the future at ETC:
- The Clinical Director will have an update list of all Pregnant Patients;
- The Clinical Director will review all Pregnant Patients' file as soon as they enter our program or current patients become pregnant; and
- The Clinical Director will review the progress of all Pregnant Patients bi-weekly.
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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 20 patient records, 15 were reviewed for urine drug screen results. The facility failed to ensure the completion of random urinalysis drug screens at least monthly in two records, # 2 and 5; both patient records did not contain documentation of a the results of a urinalysis drug screen for December, 2007.
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Plan of Correction
§715.14 (a) NM101 Urine testing
Our plan of correction was completed in January 2008. On both patients their random urine came up at the end of December. Both patients' urine leaked. By the time we found out about the leaks it was January and we had no opportunity to reschedule the patients for December.
We held an In-house Quality Control meeting where it was decided:
We held an In-house Quality Control meeting where it was decided:
- To order and start using the "Click equal sealed cup". This means that as you screw the lid of the cup on to the cup and if you hear a click the cup is sealed.
- Before our Nurses mail out the urinalysis they check the click through the sealed bag.
Plan of Correstion will be implemented by 08/04/2008
It is up to the Clinical Director to over see. |
715.19(3) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(3) After 4 years of treatment, a narcotic treatment program shall provide each patient with at least 1 hour of group or individual psychotherapy every 2 months. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of 20 patient records, 4 were reviewed for psychotherapy services for patients in treatment for more than fours years. The facility failed to document psychotherapy hours for patient # 2 between 12/13/07 - 3/13/08. The patient was assessed by the facility to need one hour of psychotherapy every two months.
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Plan of Correction
§715.19 (3) N M189 Psychotherapy services
The POC will be the hold a staff meeting and explain/educate them on the letter and spirit of the §715.19 and our policy & procedures on Psychotherapy services hours.
The Clinical Director will monitor Compliance.
The Chief Operating Officer will conduct the training by August 30, 2008 with a special emphasis on §715.19 on required hours. Chief Operating Officer is responsilble for the enforcement of §715.19. |
715.21(1)(i-iv) 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.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
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Observations
Based on a review of 20 patient records, the facility failed to comply with the limitations stated in policy, procedure, and regulation when they provided a letter to patient # 5 that informed the patient he would be discharged from the program if he did not comply with financial obligations to the facility.
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Plan of Correction
§715.21 (1) (i-iv) N M203 Patient termination.
Plan of Corrective is to hold a Mini-Training (3-hours) with all employees on explaining/educating them on the letter and spirit of the §715.21 (1) (i-iv) by August 15, 2008 Special attention will be giving to §715.21 (iv).
The Chief Operating Officer will conduct this training. The Chief Operating Officer will review and sign off on all Involuntary Discharges. |
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.
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Observations
Based on a review of 20 patient records,15 were reviewed for treatment plan content. The facility failed to provide treatment plans that addressed the specific needs of the patients as identified in psychosocial evaluations and additional documentation contained in the patient records, specifically, patient records # 1, 2, 3, 4, 7, 9, 10, 11, 12, 14, 15, and 16. Of the 15 patient records reviewed, 12 of 15 records contained global treatment plans that were not specific to the patient.
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Plan of Correction
§715.23 (d) N M269 Patient records
Plan of Corrective is to hold a Training (8-hours) with all employees on explaining/educating them on the letter and spirit of the §715.23 (d) by August 30, 2008 Special attention will be giving to using the Identified problem from the psychosocial, developing the Problem List, work off the Problem List, updating the psychosocial & Problem List as we find out about new or other problems.
We are also going to hold training on Recovery to ensure counselors understand where we are going with our treatment plans. The Clinical Director & the Chief Operating Officer will conduct this training.
Our Clinical Director is responsilble for the monitoring of the treatment plans elements. |
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.
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Observations
Based on a review of 20 patient records, 15 were reviewed for treatment plan content. The facility failed to document treatment plans that identified realistic and specific short-term goals or objectives to the attainment of treatment goals. Fourteen patient records, specifically # 1, 2, 3, 4, 6, 7, 8, 9, 10 11, 12, 14, 15 and 16, contained vague, non-specific steps to reach their goals and the time frames were generalized rather than realistically specific to the action step.
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Plan of Correction
§715.23 (d) (1) N M271 Patient records
Plan of Corrective is to hold a Training (8-hours) with all employees on explaining/educating them on the letter and spirit of the §715.23 (d)(1) by August 30, 2008 Special attention will be giving to realistic and specific short-term goals and objectives. We will also include §715.23 (d) (2) Patient records
We are also going to hold training on Recovery to ensure counselors understand where we are going with our treatment plans. The Clinical Director & the Chief Operating Officer will conduct this training.
Our Clinical Director is responsilble for the monitoring of the treatment plans elements.
John Applebee
July 30, 2008
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