INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on August 28-29, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Division of Accountability and Program Improvement. Based on the findings of the on-site 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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715.21(2) 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.
(2) A patient terminated involuntarily, except a patient who commits or threatens to commit acts of physical violence, shall be afforded the opportunity to receive detoxification of at least 7 days. The detoxification may take place at the facility or the patient may be referred to another narcotic treatment program or hospital licensed and approved by the Department for detoxification.
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Observations
The facilty failed to provide a detoxification of at least 7 days to a patient that was terminated involuntarily.
Patient records were reviewed on August 28-29, 2018. Patient #5 was involuntarily terminated from treatment on 3/5/18 for bringing a controlled substance into the facility. Patient #5 was terminated immediately from treatment and was not given a detoxification.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 8/30/2018 all patients terminated involuntarily, except a patient who commits or threatens to commit acts of physical violence, will be afforded the opportunity to receive a detoxification of at least 7 days. The detoxification will take place at the facility. Facility personnel will review regulations and policies regarding involuntary terminations on 9/12/2018. As of 8/30/18, Program Director has reviewed the process for an involuntary discharge with the NTP physicians to ensure placement of process for detoxification following the issuance of an involuntary discharge.
Compliance will be monitored through peer reviews of all medical charts. These will be completed monthly to ensure compliance regarding documentation and medical orders concerning involuntary terminations. Compliance will also be monitored monthly through open and closed chart reviews completed by the Program Director and then submitted to clinical compliance officers for additional review.
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