INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection pertaining to the plans of correction for the May 16, 2011 through May 18, 2011 methadone monitoring inspection. The follow-up inspection was conducted on September 20, 2011 by staff from the the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Soar Corp. was found not to be in compliance with the applicable chapters of 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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715.9(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
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Observations
Based on the review of patient records, the facility failed to contact the previous narcotic treatment facility for the patient's treatment history in two of two patient records reviewed.The findings include:Fourteen patient records were reviewed on September 20, 2011. Two patient records required contacting the prior narcotic treatment facility for the previous treatment history the patient's reported to have received. Patient records # 4 and 9 contained documentation the patients had received narcotic treatment services previously at other narcotic treatment programs. Both patient records reviewed did not contain documentation of any attempt to obtain the patient's prior treatment history from the previously attended narcotic treatment facilities.
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Plan of Correction
Director will issue memo to all intake personnell stating that all admits who have been in other MAT programs that their records will be sent for upon admission. Clinical supervisor will monitor for compliance during supervision and chart audits. |
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 on September 20, 2011. Two patient records required that the facility transfer specific patient files to the receiving narcotic treatment program as part of the transfer process. The facility failed to document that information was sent to the transferring program in patient record # 7. Patient # 7 was discharged as a transfer to another narcotic treatment facility June 30, 2011. There was no documentation of the required patient files being transferred to the receiving facility.
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Plan of Correction
The Clinical supervisor will do inservice with all clinical and medical staff informing them to make sure that transfer letter is sent to receiving MAT program including the last Methadone dose. A copy of the faxed information, as well as the fax conformation sheet will be added to the patients chart. The information will include but not limited to admission date, current medication dose, patient's history, psychosocial summaries, urinalysis reports or summary exception requets, and current status of the patient with a written consent for transfering this information to the provider. Clinical Supervisor will monitor for compliance during supervision and chart audits. |
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 one of one required patient records.The findings include:Fourteen patient records were reviewed on September 20, 2011. One patient record was reviewed for documentation of notification to the referring facility of the admission and dosing of the referred patient. Patient # 12 was referred by another narcotic treatment program on August 24, 2011. There was no documentation of the referring program being notified of the admission and initial dosing of the patient at the time of the inspection review. An interview with the facility director did confirm that documentation was not in the record. The director indicated that he contacted the facility; however, he failed to include documentation in the record supporting that he had made the contact.
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Plan of Correction
A memo from the Executive Director will be sent to all clinical staff, as well as read at the next two staff meetings in regard to the proper procedure to institute a transfer of a patient (person in recovery) The memo will indicate the importance of attaching a fax conformation page to each and every transfer sent to the referring agency to provide proof that the proper information was sent. The information will include the last Methadon dose the patient is receiving. All this will be in the patients chart as well as the fax conformation of the records sent. The clinical supervisor will monitor all transfer paperwork for compliance, and review it during chart aduits. |