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 December 3-4, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Directions Treatment Services 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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715.20(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.The findings include:Fourteen patient records were reviewed December 3-4, 2013. Two patient records required the facility transfer specific patient files to the receiving narcotic treatment program as part of the transfer process. Patient # 10 was discharged as a transfer to another narcotic treatment facility November 26, 2013. There was no documentation the required patient files were transferred to the receiving facility.
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Plan of Correction
By 12/30/2013, all counselors will be trained on the requirements regarding the records that must be included in order to transfer patients to another program. Beginning on 12/30/2013,counselors will include the list of files transferred to the receiving project in the patient record. The Clinical Supervisor will review for completeness the documentation of the records transferred prior to completion of the patient transfer. This review will be documented by dated signature of the supervisor. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on the review of patient records, the facility failed to complete annual evaluations in accordance with the regulations in two of four patient records reviewed. The findings included:Fourteen patient records were reviewed December 3-4, 2013. Four patient records required documentation of an annual clinical review. The annual evaluation is to be reviewed, dated and signed by the medical director. There was no signature by the physician demonstrating the review of the annual evaluation as required in patient records # 12 and # 13.
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Plan of Correction
By 12/24,counselors will be reminded that the narcotic treatment physician's review of the annual review must be documented by dated signature of the physician. As of 12/24, the narcotic treatment physicians have been instructed that the annual clinical reviews of all patients must be documented by dated signature of the physician. Ongoing compliance with the requirement will be monitored by the Clinical Supervisor during monthly and random record review. |