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 October 27 & 28, 2009 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 compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and a plan of correction is due on November 26, 2009. .
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Plan of Correction
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715.10(c) LICENSURE Pregnant patients
(c) Counseling records and other appropriate patients records shall reflect the nature of prenatal support provided by the narcotic treatment program.
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Observations
Based on a review of patient records and staff interview, the facility failed to ensure that pregnant patients' records reflect the nature of prenatal support provided by the narcotic treatment program in two of two patient records.The findings include:Seventeen patient records were reviewed on October 27 & 28, 2009, two were reviewed for content of supports provided to pregnant patients. The patients, #2 and 10, were identified as pregnant at admission, however the preliminary treatment planned failed to document the pregnancy and provide necessary treatment.
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Plan of Correction
All admissions documentation of pregnant women will be reviewed by the Clinical Supervisor to insure that the pregnancy is identified on the initial treatment plan as a significant issue and that the corresponding services, supports and referrals are likewise specified. The Clinical Supervisor will also consult on an ongoing basis with the counselor to insure that the patient is receiving the services, and following through with referrals and that these are being documented on subsequent treatment plan updates, throughout the pregnancy. This change will be put into effect immediately. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on a review of patient records, the facility failed to document follow-up information in three of six patient records.The findings include:Seventeen patient records were reviewed 10/27 & 10/28/2009, six were reviewed for follow-up information content. Patient records # 13, 14 and 15 did not contain documentation of follow-up after patient discharge. Patient # 13 was discharged from treatment 6/4/09, patient #14 was discharged 7/21/09 and patient # 15 was discharged 6/16/09.
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Plan of Correction
Under the direction of the Program Director an administrative assistant generated a list of all patients discharged in the past six months and reviewed the charts to insure that follow-up information was properly documented. In instances where it was not in the chart, the chart was returned to the patient's counselor to update this information. The resubmission of these charts with the completed information was reviewed by the same administrative assistant and subsequently by the Program Director. Going forward an administrative assistant has been tasked with sending out follow up letters at the beginning of each month to patients discharged in the prior calendar month and tracking the responses. A copy of the follow-up letter is placed in the chart at the time the original is sent to the patient's last know address. Any letters that are returned are likewise inserted into the chart and copy is made for the counselor's review. The administrative assistant signs and the Program Director countersigns a document indicating the follow-up letters due that months were sent. This procedure is in effect now. |