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 and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on December 3 through 6, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northeast Treatment Centers - Net Steps was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and a plan of correction is due on January 1, 2008.
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Plan of Correction
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715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on random review of 22 patient records, two of three annual physicals were completed more than 14 days late, patient record #2 and #15.
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Plan of Correction
The Medical Director will oversee the scheduling and completion of annual physical exams to insure that they are completed within 14 days of the anniversary date. The medical records department will monitor the completion of the annual physical examination in their routine QA chart audit process.
Responsible Person and time lines--
Medical Director for scheduling and completion by Feb 05, 2008
Data Manager for modification of chart audit instrument by Feb 05, 2008
Medical Records staff for chart audit monitoring & reporting by Feb.05, 2008 |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on the review of administrative documentation and staff interviews, the facility failed to submit a written report for unusual incidents with the potential for negative community reaction.
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Plan of Correction
POC- The Program Director will provide staff training on critical incidents and the reporting requirements.The management team will submit and review the critical incidents with the Director. The incidents will be used as part of the QA process as a vehicle to identify operational or staff performance issues. The critical incidents will be reviewed monthly by the director and data manager to insure compliant incident reporting.
Responsible Person and Time Lines-
Net Steps Training Coordinator will schedule staff training by Jan 15, 2008
Program Director will provide training by Jan 30, 2008.
Director and Date Manager will schedule and review all critical incidents on a 1x per month basis starting 1/30/2008,
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