INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on 12/29/2015 and 12/30/2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Clinical Outcomes Group Incorporated 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:
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Plan of Correction
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715.9(a)(4) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(4) Have a narcotic treatment physician make a face-to-face determination of whether an individual is currently physiologically dependent upon a narcotic drug and has been physiologically dependent for at least 1 year prior to admission for maintenance treatment. The narcotic treatment physician shall document in the patient 's record the basis for the determination of current dependency and evidence of a 1 year history of addiction.
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Observations
Based on a review of client records, the facility failed to ensure client records contained documentation from a physician that the clients were currently physiologically dependent on a narcotic drug and or had been physiologically dependent on a narcotic drug for at least 1 full year prior to admission for maintenance treatment.
The findings include:
Three out of five client records reviewed on 12/29/2015 and 12/30/2015, required documentation by a physician that the clients had been physiologically dependent on a narcotic drug for at least 1 prior to admission for maintenance treatment, and did not have documentation the clients had been physiologically dependent on a narcotic drug for 1 year prior to admission for maintenance treatment.
Client #1 began narcotic maintenance treatment at the facility on 02/11/2015, and was discharged on 08/24/2015, but the facility did not have documentation from a physician that the client had been physiologically dependent on a narcotic drug for 1 year prior to beginning maintenance treatment.
Client #2 began narcotic maintenance treatment at the facility on 02/21/2015, and was an active client at the time of the onsite inspection, but the facility did not have documentation from a physician that the client had been physiologically dependent on a narcotic drug for 1 year prior to beginning maintenance treatment.
Client #4 began narcotic maintenance treatment at the facility on 02/21/2015, and was an active client at the time of the onsite inspection, but the facility did not have documentation from a physician that the client had been physiologically dependent on a narcotic drug for 1 year prior to beginning maintenance treatment.
The findings were reviewed with the facility staff during the inspection process.
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Plan of Correction
The facility director will meet with our Suboxone doctors to review the specific requirements for those clients currently enrolled in the medication assisted program and those waiting for admission to ensure that they correctly documenting a physiological dependence of a minimum of one year on a narcotic drug.
The facility director will have the doctor complete an addendum for client #1, #2 and #4 documenting a minimum of one year of a physiological dependence on a narcotic drug. This will be completed by 2/28/2016.
Facility Director will review cases quarterly to ensure compliance. The facility will be in full compliance by 2/29/2016.
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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 client records, the facility failed to ensure that clients receiving narcotic maintenance treatment received the required hours of psychotherapy for the length of time they have been receiving narcotic maintenance treatment.
The findings include:
Five client records for narcotic maintenance treatment clients were reviewed on 12/29/2015 and 12/30/2015. In one of the five records reviewed, the facility failed to provide the required hours of psychotherapy for the length of time the client was receiving narcotic maintenance treatment.
Client #2 began narcotic maintenance treatment on 09/19/2014, and was an active client at the time of the onsite inspection. The required psychotherapy for the client was 2.5 hours monthly, including at least 1 hour of individual psychotherapy. The client received 0 hours of individual psychotherapy from February 2015 through October 2015
The findings were reviewed with the facility staff during the inspection process.
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Plan of Correction
The facility director will review with clinical staff and clients the counseling requirements for the Suboxone program. The clinical staff will be directed to schedule a minimum of one hour of individual counseling with their clients monthly in addition to their group counseling schedule. The facility director will review this monthly to ensure compliance. The facility will be in full compliance by 02/29/2016. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records the facility failed to document a treatment plan update at least every 60 days in three of nine records reviewed.
The findings include:
Nine client records requiring documentation of a treatment plan update were reviewed during the renewal inspection on 12/29/2015 and 12/30/2015. The facility failed to document a treatment plan update at least every 60 days in client records 2, 3 and 5.
Client #2 was admitted on 08/29/2014, and was still an active client at the time of the inspection. Client #2 ' s treatment plan update dated 11/17/2015, was completed 64 days after the previous treatment plan dated 9/14/2015.
Client #3 was admitted on 12/13/2013, and was still an active client at the time of the inspection. Client #3 ' s treatment plan update dated 08/20/2015, is the only treatment plan update completed for the year 2015.
Client #5 was admitted on 10/24/2012, and was still an active client at the time of the inspection. Client #5 ' s treatment plan update dated 11/23/2015, was completed 62 days after the previous treatment plan dated 9/22/2015.
The findings were reviewed with the facility staff during the inspection process.
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Plan of Correction
The facility director will review with all staff the treatment plan update requirements in our bi-monthly supervision by 02/10/2016. A plan will be developed in the event that counselors will be on vacation or holiday falls around the time an update is due. This will be reviewed monthly to ensure compliance.
The facility director will meet with the counselors of Client #2, Client #3and Client #5 to make sure appropriate addendums are completed to ensure compliance.
The facility will be in full compliance as of 02/28/2016. |