INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection pertaining to the plans of correction for the January 6, 2011 methadone monitoring inspection. The follow-up inspection was conducted on August 22, 2011 by staff from the the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Foundations Medical Services, LLC 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(e) LICENSURE Intake
(e) A narcotic treatment program shall secure a personal history from the patient within the first week of admission. The personal history shall be made a part of the patient record.
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Observations
Based on a review of patient records and an interview with a counselor, the facility failed to document that a personal history form the patient was completed within the first week of admission, as required by regulation, in six of seven patient records.
The findings include:
Seven of the patients reviewed were required to include documentation of a personal history that was completed within one week of the date of admission. The facility did not document the personal history within the first week of admission in patient records # 8, 9, 10, 11, 12 and 13.
Patient #8 was admitted on April 14, 2011. The personal history was not dated and therefore it could not be determined that the personal history had been completed within the first week of admission.
Patient #9 was admitted on April 16, 2011. The personal history was not dated and therefore it could not be determined that the personal history had been completed within the first week of admission.
Patient #10 was admitted on April 21, 2011. The personal history was not dated and therefore it could not be determined that the personal history had been completed within the first week of admission.
Patient #11 was admitted on June 3, 2011. The personal history was not dated and therefore it could not be determined that the personal history had been completed within the first week of admission.
Patient #12 was admitted on April 7, 2011. The personal history was not dated and therefore it could not be determined that the personal history had been completed within the first week of admission.
Patient #13 was admitted on April 21, 2011. The personal history was not dated and therefore it could not be determined that the personal history had been completed within the first week of admission.
An interview with a counselor took place on August 22, 2011. It was confirmed that no completion date was documented to show when the personal history was completed for the aforementioned patients.
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Plan of Correction
Due to complications not within the programs control, updates to our electronic record could not occur until 4/16/11. At which time the signature and date line was added to the form. As noted 4 records remained non-compliant even beyond that date. Counselors were re trained by the Program Director on the regulation and policy addressing the 7 day requirement.
1. Random monthly audits will be conducted by the Program Director.
2. Compliant Audits will be conducted by the Corporate Compliance Officer.
3.Monthly peer review will be conducted by the counselors.
All audits and reviews will be conducted to ensure compliance. |
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 and an interview with a counselor, the facility failed to document that it transferred patient records which included admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, current status of the patient and contained the written consent of the patient in two of four patient records.
The findings include:
Eighteen patient records were reviewed on August 22, 2011. Four of the patient records reviewed represented patients who had transferred to another narcotic treatment facility and required a transfer of patient records which included admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, current status of the patient and contained the written consent of the patient. There was no documentation that the facility transferred the documentation in patient records # 10 and 17.
Patient # 10 was admitted on April 21, 2011 and transferred to another narcotic treatment program on May 7, 2011. There was no documentation that the the transferring narcotic treatment program transferred patient records which included admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, current status of the patient and contained the written consent of the patient.
Patient # 17 was admitted on January 2, 2011 and transferred to another narcotic treatment program on June 17, 2011. There was no documentation that the the transferring narcotic treatment program transferred patient records which included admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, current status of the patient and contained the written consent of the patient.
An interview with a counselor took place on August 22, 2011 and it was confirmed that there was no documentation to show that the required transfer documentation was sent for each of the aforementioned transferred patients.
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Plan of Correction
1. The Project Director will retrain counselors on the policy regarding transferring patients to other facilities on September 8, 2011.
2. All transfer discharges will be given to the Program Director within 5 days of request. Program Director will ensure that required paperwork has been submitted to recieving Narcotic Treatment Program and the request and completion of transfer has been documented in client chart. |