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 August 26-28, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Habit OPCO, Inc.- Pottstown was found not to be in compliance with the applicable chapters of 4 PA Code and 28 PA Code which pertain to the facility.
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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 the review of patient records, the facility failed to transfer the required patient files in one of two patient records reviewed.
The findings include:
Twenty patient records were reviewed August 26-28, 2014. Two patient records required the facility transfer specific patient files to the receiving narcotic treatment program as part of the transfer process.
Patient # 9 was discharged as a transfer to another narcotic treatment facility June 13, 2014. The documentation reviewed demonstrated the facility failed to transfer all of the required information. It did not include the admission date and medical summaries. In addition, the written consent signed by the patient did not identify all of the information that was submitted to the receiving facility, but was restricted to 4 PA Code 255.5.
These findings were reviewed the facility staff during the licensing process.
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Plan of Correction
All counselors will be re-trained on the process of transferring a patient to another narcotic tx program by 10/1/14. A policy review will occur, indicating the specific paperwork to be sent to the transferring clinic, as well as review of the how this information is to be released with the appropriate written consent. Counselors will be required to have information reviewed by CD or designated staff, prior to releasing information to transferring clinic within 7 days of the requested transfer. |
715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document what materials were sent to the receiving narcotic treatment program in one of two patient records reviewed.
The findings include:
Twenty patient records were reviewed August 26-28, 2014. Two records required documentation of the materials sent to the receiving provider of the transfer.
Patient # 10 was transferred to another narcotic treatment program within the project as an internal transfer. The facility failed to document what, if any, information was transferred. Upon discussion with facility staff, it was learned the procedure used to transfer patient records is to send the entire original patient record to the receiving facility after copying the entire record to remain on site. However, there was no documentation indicating this had been done for patient record # 10.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All counselors will be re-trained on the process of internal transfers by 10/1/14.
Appropriate documentation will be completed, indicating all information sent, and review of the documentation by will be conducted by CD or designated staff, prior to the completion of the transfer.
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