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 22-24, 2012 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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715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
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Observations
Based on the review of patient records, the facility failed to ensure the physician documented in the patient record the rationale for granting take home medication in three of four patient records.The findings include:Fourteen patient records were reviewed October 22-24, 2012. Four patient records were reviewed for take home medication documentation. Per regulation, the narcotic treatment physician shall document in the patient record the rationale for permitting take home medication. Patient records # 2, 3, and 4 did not contain documentation of the physician's rationale for granting the take home medication.
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Plan of Correction
All doctors orders granting take home medication, as well the rational for the take home medication will be documented by the physician (MD/DO)on a Take home form, as well as on an excel spread sheet. The training for the Soar physician and clinical staff will be done by 11/22/2012. The counselor will be responsible for getting the signed paperwork from the doctor and putting it into the patients chart. The supervisor will be responsible to see that the patient's counselor was compliant with getting the paperwork into the chart during monthly supervision and entered into the Excel spread sheet. |
715.17(b) LICENSURE Medication control
(b) A narcotic treatment program shall develop policies and procedures regarding verbal medication orders, including the issuing and receiving of orders, identifying circumstances when orders are appropriate and documenting orders, in accordance with applicable Federal and State statutes and regulations.
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Observations
Based on the review of patient records, the facility failed to ensure the physician dated the signature after submitting a verbal order in one of one patient records reviewed. The findings include:Fourteen patient records were reviewed October 22-24, 2012. One patient record contained documentation of a physician's verbal orders on two separate occasions. Patient # 2 was admitted November 18, 2011. On August 8, 2012 and on September 15, 2012, there was documentation of nursing notes describing verbal orders received over the telephone from the medical director. There was no documentation with the physician's signature for either of those telephone verbal orders.
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Plan of Correction
All verbal orders will be signed only by the doctor who gave the order. The verbal order given will be written in the nursing log book. The physician must sign and date the verbal order within 24 hours of the time the order was given. Soar will create an Excel spread sheet to keep track of the orders. The lead nurse will be responsible for tracking the order to be signed within the required time. The nursing director or RN will oversee this is done in accordance with the state regulations. An in-service training for the Soar staff physician, as well as all clinical staff will be done by 11/22/2012. |
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 three patient records.The findings include:Fourteen patient records were reviewed October 22-24, 2012. Three patient records required the facility transfer specific patient files to the receiving narcotic treatment program as part of the transfer process.Patient # 13 was discharged as a transfer to another narcotic treatment facility July 20, 2012. There was no documentation that all of the required patient information were transferred to the receiving facility prior to the transfer of the patient. A review of the patient record revealed eight pages were sent on July 18, 2012, which did not account for all of the required information. The receiving facility sent three separate requests for patient records. The patient record included documentation that on August 23, 2012 more patient information was then sent to the receiving facility with an apology for the delay in providing the requested information.
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Plan of Correction
It will be the responsibility of the intake coordinator for all patients transferred from Soar to another facility and to insure approval, as well as fax all required documentation to be sent to the receiving agency within the required state regulations. A spread sheet will be made to capture all transfers being made. A training on the proper procedure for transferring patients will presented to the clinical staff by the Intake Coordinator and the training will be done by November 22, 2012. It will be the responsibility of the Intake coordinator to see that all clinical and/or support staff working on the transfer process will insure the proper procedure for the transfer is completed. The clinical supervisor will check the spread sheet and the documentation during monthly supervisions. |
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 five patient records.The findings include:Fourteen patient records were reviewed October 22-24, 2012. Six patient records were reviewed for complete discharge summaries. Patient records # 9, 10, 11, 12, 13 and 14 were all discharge records with discharge summaries required. However, The discharge summaries failed to include the reason for treatment, services offered or the condition or prognosis, and the patient at the time of discharge.
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Plan of Correction
There will be a training and a information sheet on what is necessary to include in a discharge summary. The training will be done by November 22. It will be the responsibility of the clinical supervisors to review this documentation at the time of discharge during that monthly supervision and put in a Excel spread sheet. |
715.29(5) LICENSURE Exceptions
A narcotic treatment program is permitted, at the time of application or any time thereafter, to request an exception from a specific regulation.
(5) If the exception relates to a specific patient, the narcotic treatment program shall maintain documentation of the exception in the patient 's record.
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Observations
Based on a review of patient records, the facility failed to maintain documentation of the exception for take home medication in two of two patient records reviewed.The findings include:Fourteen patient records were reviewed October 22-23, 2012. Two patient records required documentation of take home medication provided in exceptional circumstances.Patient # 1 was admitted February 2, 2011 and was listed as a patient receiving six take home medication bottles weekly for medical reasons. The exception documentation was not in the patient record at the time of the monitoring survey.Patient # 2 was admitted November 18, 2011. The patient was provided with take home medication bottles for medical reasons. There was no exception documentation in the patient record at the time of the monitoring survey.
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Plan of Correction
The take home exception paperwork will be put on the official PA State form. All exception take homes will be approved by a committee including the Soar staff physician, nurse, counselor and supervisor. The supervisor of the counselor with that patient will be responsible to see the proper paperwork is put into the patients chart. This committee including the staff medical doctor will be set up and trained on the process and will be done on or before November 22, 2012, the training will include the standard procedure for take home medication, as well as the exception take home medication and the difference between both will be defined. All the Soar Clinical staff will be at the mandatory trainings. Two trainings will be held. The Clinical supervisors will be responsible to see that the proper procedure takes place. |