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 September 17, 2013 to September 19, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of 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 inspection.
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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 September 17-19, 2013. Three patient records were reviewed for documentation of notification to the referring facility of the admission and the date of first dosing of the referred patient. Patient # 10 was admitted as a transfer from another narcotic treatment program on August 19, 2013. The patient's initial dose date was also August 19, 2013. There was no documentation the referring narcotic treatment program was notified of the admission and dosing of the referred patient. Patient # 14 was admitted as a transfer from another narcotic treatment program on August 8, 2013. The patient's initial dose date was August 9, 2013. There was no documentation the referring narcotic treatment program was notified of the admission and dosing of the referred patient. This is a repeat deficiency from the October 2012 methadone monitoring inspection.
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Plan of Correction
All transfers will now go through the intake department who will be charged with all paperwork related to transfers both into and out of Soar. Memo and inservice training will be given to Intake Dept with clear instructions on what and how to do a transfer including all letters that have to go back and forth between the two facilities. The Q and A staff member will be charged with following up on this to make sure that it is done in a timely manner. |
715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
Based on the review of patient records and discussion with facility staff, the facility failed to complete all required laboratory tests as part of the admission process in four of five patient records reviewed. The findings include:Fourteen patient records were reviewed September 17-19, 2013. Five patient records were reviewed for completed laboratory tests as part of the admission process, specifically a tuberculosis Mantoux test (PPD). Patient records # 3, 9, 10 and 11 did not have documentation of the tuberculin Mantoux test having been administered as part of the admission process. Discussion with the facility administrative staff revealed there had been a shortage of the Tuberculin Purified Protein Derivate for Intradermal Injection. However, the facility never reported the shortage to the Department, nor requested an exception.
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Plan of Correction
Next time there is a shortage of the Mantoux test Soar will report and send an exception request to DDAP. All pts will receive the test now that the test is being made available to us again. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
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Observations
Based on a review of patient records, the facility failed to document all of the required information in four of four patient records.The findings include:Fourteen patient records were reviewed September 17-19, 2013. Four patient records were reviewed for complete discharge summaries. Patient # 5 was admitted October 9, 2012. The patient record indicated the patient had died but there was no discharge summary completed at the time of the inspection. Patient # 11 was admitted April 15, 2013 and discharged as of June 8, 2013. There was no documentation of the reason the patient entered treatment, the services offered the patient while in treatment, or the status of the patient upon discharge. Patient # 12 was admitted March 29, 2011 and discharged as of July 15, 2013. There was no documentation of the reason the patient entered treatment, the services offered the patient while in treatment, the progress/lack of progress or the status of the patient upon discharge. Patient # 13 was admitted December 21, 2011 and discharged as of February 19, 2013. There was no documentation of the reason the patient entered treatment, the services offered the patient while in treatment, or the status of the patient upon discharge. This is a repeat deficiency from the inspection conducted in October 2012.
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Plan of Correction
Clinical supervisors will coduct an in-service training for all clinical staff on the correct way to do a discharge summary. In addition, the Q and A Dept will be charged with making sure that in doing charge audits that all discharge summaries are in the charts and also done correctly. Issue will also be addressed in weekly supervision with clinical staff as needed. |