INITIAL COMMENTS
|
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 August 16 -17, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Summit Medical Services 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 and a plan of correction is due on September 13, 2007. .
|
Plan of Correction
|
715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
|
Observations
Based on a review of client records it was determined that the facility failed to provide a signed release of information prior to disclosing information from client record # 16.
|
Plan of Correction
The release had been sent from another facility prior to SMS releasing the information. Unfortunately, this release was for the other facility to send us information as opposed to requesting information from us. In order to prevent this from occurring in the future, all release forms that come into the clinic requesting any information shall be reviewed by a supervisor prior to being passed on to the party responsible for releasing the information. This should prevent any further problems in this area. We will also review the procedures for releasing information in a staff meeting.
The Facility Director and/or the Project Director will be responsible to monitor this area. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
|
Observations
Based on a review of client records on August 17, 2007 it was determined that the facility failed to provide a complete medication order. The document in question was dated 5-22-07. Client record # 12 contained a medication order which requested a decrease in medication. The medication order was signed by the physician but was not processed for an increase or a decrease.
|
Plan of Correction
This appears to have been a very isolated incident as SMS nursing staff reviewed a large sample of charts to try and find any additional problems in this area. None were found. It should also be noted that the patient chart was a discharge file and that this patient never returned to the facility to receive the dosage adjustment.
In order to try and prevent this in the future all physician's orders shall be reviewed by the nursing staff prior to placing the order in the patient chart and filing it in the computer. The nurisng staff shall sign off as to who noted this into the patient chart. The physician shall also be made aware to be more vigilant in this area.
This shall be monitored by clinic physicians and nursing staff. |
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.
|
Observations
Based on a review of client records on August 17, 2007 it was determined that the facility failed to provide the required information for a transfer out for client record # 15. The information that was missing included the client's admission date and the medical and psychosocial summaries.
|
Plan of Correction
This deficiency was found in the same chart as the first deficiency. It was based on the same release that had been sent by the Facility where the patient was transferring. The release only requested four areas to be addressed and thus that was all the information that was sent. Also the patient had already begun dosing at the other facility and was no longer planning on returning to SMS.
In the future if this were to occur, the consent form would be refaxed to the requesting facily asking for that facility to send a new release form requesting all the necessary information that SMS is required to send. If the patient was attempting to facilitate a transfer while still an active patient at SMS, the patient would be asked to sign a consent form allowing SMS to release all the necessary information to the new Facility.
Once again all requests for information shall be reviewed by a supervisor prior to being assimilated to the person responsible prviding the necessary information to the requesting party.
This procedure shall be reviewed in a staff meeting.
All in all it shall be the responsibilty of the Facility Director and/or the Project Director to monitor this situtaion. |