This report is a result of an onsite follow-up inspection pertaining to the plans of correction for the March 21, 2012 methadone monitoring inspection. The follow-up inspection was conducted on November 6-8, 2012 by staff from the the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Tadiso, Inc., 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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Observations
Based on a review of patient records, the facility failed to document case consultations, as per agency policy in March, June, September and December each year, in eight of ten patient records.
The findings include:
Fourteen patient records were reviewed on November 6-8, 2012. Case consultations were required to be completed in ten patient records. Case consultations were not documented in March, June, September, and December, as per agency policy, in patient records #1, 2, 4, 5, 6, 7, 10 and 11.
Patient #1 was admitted May 7, 2012. Case consultations were due to be completed in June and September 2012. There were no case consultations documented in patient record #1.
Patient #2 was admitted March 22, 2012. Case consultations were due to be completed in June and September 2012. There were no case consultations documented in patient record #2.
Patient #4 was admitted June 13, 2012. A case consultation was due to be completed in September 2012. There were no case consultations documented in patient record #4.
Patient #5 was admitted May 3, 2012. Case consultations were due to be completed in June and September 2012. There were no case consultations documented in patient record #5.
Patient #6 was admitted February 1, 2012. Case consultations were due to be completed in March, June and September 2012. There were no case consultations documented in patient record #6.
Patient #7 was admitted January 26, 2012. Case consultations were due to be completed in March, June and September 2012. There were no case consultations documented in patient record #7.
Patient #10 was admitted April 17, 2012. Case consultations were due to be completed in June and September 2012. There were no case consultations documented in patient record #10.
Patient #11 was admitted June 29, 2012. A Case consultation was due to be completed in September 2012. There were no case consultations documented in patient record #11.
An interview with the clinical supervisor took place on November 8, 2012 at which time the aforementioned information was confirmed.
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Plan of Correction
All quarterly and annual case consultations will be conducted by the assigned counselor with the medical doctor and a member of the Social Services Supervisory staff or Administration. The results of the conference will be documented and signed by the Doctor and the patient, if present. The quarterly and annual evaluations will be conducted based on the patient's admission date. All quarterly and annual evaluations will be reviewed by either the Social Services Coordinator or the Director of Social Services. |