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 January 29, 2013 - February 1, 2013 by staff from the Division of Drug and Alcohol Program Licensure. 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 4 PA Code and 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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715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on the review of patient records, the facility failed to ensure a random drug-screening urinalysis was completed in one of eighteen patient records.
The findings include:
Nineteen patient records were reviewed January 29-31, 2013. Eighteen patient records were reviewed for monthly urine drug screen results.
Patient record # 6 - patient was admitted to treatment on August 23, 2012 and discharged on December 10, 2012. A urine drug screen was missing for September 2012.
The findings were reviewed with the director and were not disputed.
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Plan of Correction
Effective February 11, 2013, Nursing and Clinical staff will ensure that the date the urine specimen was obtained, not the day results were received, is inputted into AMS. This will ensure that the urines are completed monthly for each client. This process will be monitored by nursing staff monthly and adjusted accordingly to ensure compliance and accuracy. |
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 three patient records.
The findings include:
Nineteen patient records were reviewed January 29-31, 2013. The files of three patients were required to be transferred to the receiving narcotic treatment program as part of the transfer process. One patient record did not include documentation of the transfer of the required files.
Patient # 2 was admitted on August 10, 2011 and discharged as a transfer to another narcotic treatment facility on September 13, 2012. There was no documentation of the required patient files being transferred to the receiving facility.
The findings were reviewed with the director and were not disputed.
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Plan of Correction
Program Director will review transferring procedure, more specifically sending required transferring paperwork to receiving MNTP, with the nursing staff by February 28, 2013. Fax verification sheet will provide as evidence that information was sent. Fax transmittal sheets will then be kept in the client's medical file. Verification of transfer forms will be added to the discharge checklist and monitored monthly by the Program Director through random chart reviews. |