INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone and buprenorphine monitoring inspection conducted on July 11, 2023 through July 12, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, RHD Montgomery County Methadone 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:
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Plan of Correction
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715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the narcotic treatment program failed to transfer patient files which is to include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient in one of one applicable patient records reviewed.
Patient #5 was admitted on February 17, 2023 and was transferred to another narcotic treatment provider on May 25, 2023. There was no documentation in the record indicating that the receiving narcotic treatment program was notified of the date of admission, medical and psychosocial summaries, urinalysis reports or summary, exception requests, and current status of the patient.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An outgoing transfer fax template was developed 7/18/23 to remind staff what documentation needs to be including in transfer packets. Program Director will review the regulation, the new fax cover sheet, and transfer requirements with staff in an in-service scheduled for 8/7/23. Clinical supervisors will continue to do periodic chart reviews for compliance which will then be reviewed in monthly supervisions. |
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 ensure that treatment and rehabilitation plans are reviewed and updated at least every sixty days in five of seven client records reviewed.
Client #1 was admitted to the outpatient maintenance activity on March 12, 2021 and was active at the time of inspection. A treatment plan update was completed on February 15, 2023, and the next update was due no later than April 15, 2023; however, the update was completed on May 31, 2023.
Client #3 was admitted to the outpatient maintenance activity on October 25, 2022 and was active at the time of inspection. A treatment plan update was completed on December 28, 2022, and the next update was due no later than February 28, 2023; however, the update was completed on March 28, 2023.
Client #4 was admitted to the outpatient maintenance activity on June 6, 2016 and was active at the time of inspection. A treatment plan update was completed on September 6, 2022, and the next update was due no later than November 6, 2022; however, the update was completed on November 14, 2022. Additionally, a treatment plan update was completed on March 6, 2023, and the next update was due no later than May 6, 2023; however, the update was completed on May 11, 2023.
Client #6 was admitted to the outpatient maintenance activity on August 2, 2022 and was discharged on January 24, 2023. A treatment plan update was completed on September 7, 2022, and the next update was due no later than November 7, 2022; however, the update was completed on November 14, 2022.
Client #7 was admitted to the outpatient maintenance activity on June 19, 2018 and was discharged on April 17, 2023. A treatment plan update was completed on September 19, 2022, and the next update was due no later than November 19, 2022; however, the update was completed on November 23, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will retrain timelines for treatment plans at the 8/7/23 in-service for staff. Clinical supervisors will continue to monitor compliance during monthly supervisions and chart audits. |