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 March 19-21, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Tadiso, Inc 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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715.23(b)(14) LICENSURE Patient records
(b) Each patient file shall include the following information:
(14) Case consultation notes regarding the patient.
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Observations
Based on the review of patient records, the facility failed to document case consultations in thirteen of seventeen patient records.
The findings include:
Twenty nine patient records were reviewed on March 19-21, 2012. Seventeen patient records reviewed required documentation of a case consultation note. Per policy, the case consultations are to be completed quarterly. The facility did not document quarterly case consultations in patient records # 2, 3, 4, 5, 6, 7, 8, 15, 16, 17, 18, 19, 23 and 24. Although there were notes documented in the patients records as case consultation notes, the note did not identify the persons attending the consultation by either listing the individuals present or by identifying that the counselor and the supervisor had consulted on the case. The case consultations were signed by the counselor and the supervisor on different dates. There were also case consultations notes where the supervisor also signed as the counselor.
An interview with the project/facility director and the clinical supervisor on March 21, 2012 confirmed the findings.
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Plan of Correction
All quarterly and annual reviews will be conducted by the assigned counselor with a Social Services supervisor at which time the consultation form will be completed and signed by the counselor and the supervisor. The quarterly reviews are done at the end of each quarter of the calendar year (March, June, September, and December) and the annual reviews are completed in July of each year for the previous year. Action plan was implemented April1, 2012 and the quarterly reviews that are currently being completed are being reviewed with Social Services Department supervisors. |
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 the review of patient records, the facility failed to document a seven day follow-up contact for referred patients in two of four patient records.
The findings include:
Twenty nine patient records were reviewed on March 19-21, 2012. Nine patient records reviewed required follow-up information. Four of the nine patient records were reviewed for the completion of the seven day follow-up required for referred patients. The facility did not document a seven day follow-up in patient records # 10 and 13.
Patient # 10 was admitted on May 23, 2007 and was discharged as a transfer to another narcotic treatment program on November 10, 2011. Follow-up was to be completed by November 17, 2011. Follow-up was completed on January 13, 2012.
Patient # 13 was admitted on August 15, 2011 and was discharged as a transfer to another narcotic treatment program on October 12, 2011. Follow-up was to be completed by October 19, 2011. There was no documentation that a follow-up had been completed as of March 21, 2012.
An interview with the project/facility director and the clinical supervisor on March 21, 2012 confirmed the findings.
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Plan of Correction
All patients referred for transfer to an alternatie treatment program will have their transfer completion confirmed by Tadiso's medical personnel who verbally confirm the patient's dosage at the time of transfer. The medical personnel will note in the patient's chart that Tadiso has been contacted by the receiving agency who has confirmed that the transfer has been successfully completed. This action plan will be implemented effective 4/16/2012. |