INITIAL COMMENTS
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This report is a result of an administrative review of the written report of the findings of an on-site methadone monitoring inspection conducted for the approval to use a narcotic agent, specifically Methadone, in the treatment of narcotic addiction. This inspection was conducted on October 22 to October 24, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the administrative review of findings from the on-site inspection, Soar Corp., 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 administrative review:
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Plan of Correction
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715.20(4) 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.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on the review of patient records, the facility failed to document that it notified the referring facility of the admission and initial dosing of the patient in two of three patient records reviewed.The findings include:Fourteen patient records were reviewed October 22-23, 2012. Three patient records were reviewed for documentation of notification to the referring facility of the admission and initial dosing date of the referred patient. Patient records # 3 and 8 were referred by another narcotic treatment program and there was no documentation of the referral being notified of the admission and initial dosing of these two patients.
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Plan of Correction
We are changing our way of handling a transfer. The patient dose will be faxed to the accepting facility and a copy of the fax transmission will be put into the patient chart. All transfer paperwork and initial dose will be sent by the intake coordinator and/or assistant. Documentation will also be done in an Excel spread sheet. The Supervisor will be responsible to see that this procedure is done during the monthly supervision.A training on the new procedure will be done by 11/22/2012 for all clinical staff so everyone knows the procedure. |