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 July 29, 2013 to July 30, 2013, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, SOAR Corporation Chester 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.
|
Plan of Correction
|
715.9(c) LICENSURE Intake
(c) If a patient was previously discharged from treatment at another narcotic treatment program, the admitting narcotic treatment program, with patient consent, shall contact the previous facility for the treatment history.
|
Observations
Based on the review of patient records, the facility failed to contact the previous narcotic treatment program for the patient's treatment history in two of two patient records reviewed.
The findings include:
Eleven patient records were reviewed on July 29 to 30, 2013. Two patient records required documentation of contact with a narcotic treatment program for the previous treatment history that was reported by the patient, # 4 and 10.
Patient record # 4 contained documentation the patient had received narcotic treatment services at another narcotic treatment program. The facility failed to document an attempt to obtain the patient's prior treatment history from the previously attended narcotic treatment program.
Patient record # 10 contained documentation the patient had received narcotic treatment services at another narcotic treatment program. The facility failed to document an attempt to obtain the patient's prior treatment history from the previously attended narcotic treatment program.
The findings were reviewed and confirmed with the Facility Director.
|
Plan of Correction
The Executive Director shall complete an in-service with the intake staff of the facility by 8/16/13 to educate staff on the state regulations 715.9 Part C obtaining information from a previous narcotic provider. During intake, attempts to obtain this information will be completed by fax, the fax confirmation sheet will be filed in the chart as evidence of completion and the process will be completed by the intake worker at the intake assessment. New admissions will be audited monthly by the Program Manager, and Executive Director to ensure completion. Failures to complete will be addressed during this audit |
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.
|
Observations
Based on the review of patient records, the facility failed to document orders where appropriate in five of eleven patient records reviewed.
The findings include:
Eleven patient records were reviewed on July 29 to 30, 2013. All patient records required documentation of physician orders. Patient records # 1, 2, 4. 6 and 10 had orders not signed and dated by the narcotic treatment physician.
Patient record # 1 had a verbal order to return to dose onsite after an inpatient treatment stay. The verbal order was dated by the nurse on 2/6/2013. The verbal order was not signed and dated by the physician therefore it could not be verified that it was reviewed by the prescribing physician within 24 hours.
Patient record # 2 had an order dated 5/31/2013 for the patient to have a 5 mg increase in dose. The order was not signed and dated by the physician. The patient record documented a dose increase to 100 mg given to the patient on 6/20/2013 at 9:57 a.m. The physician order was not signed and dated.
Patient record # 4 documented a dose decrease to 68 mg given to the patient on 2/8/2013. The physician had ordered a taper that was not signed or dated.
Patient record # 6 documented the patient received a travel exception for 7 take home bottles. The physician order and justification for the travel doses was not signed and dated.
Patient record # 10 was readmitted on 4/9/2013 with a dose of 30 mg. The physician order for the initial dose was not signed or dated.
The findings were reviewed and confirmed with the Facility Director.
|
Plan of Correction
The Executive Director and Regional Project director will have fax machines and dedicated fax lines installed in each site of Soar within the Nursing station by 9/6/13. When the Md is offsite and at the secondary site of Soar, Verbal orders will be faxed the MD who will sign the order and fax it back to the site in need of the signed verbal order. The Director of Nursing Shall complete an instructional Memo for all nurses at both sites on securing and faxing the verbal order request. The instructional memo shall be completed by 9/6/13.
On Site orders shall be corrected in the following manner. As of 8/2/13 the executive Director has completed a meeting with the agency's MD and Medical Director to discuss findings and instruct on the need to print orders. The Office manager will set the appointments for the MD daily. MD will now turn in their printed signed notes to the office manager who will be responsible for checking for dates and signatures. Office manager will cross check turned in notes to the appointment list to identify and missing notes. Any missing notes from the cross check will be printed, and submitted to the MD on their next day at the facility for signatures In service will be completed by 8/23/13. And written instructions will be given to the office management and MD's from the executive director on the procedure by 8/23/13 |
715.20(4) 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.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
|
Observations
Based on the review of patient records, the facility failed to document that it notified the referring facility of the admission and initial dosing of the patient in 1 of 1 patient record reviewed.
The findings include:
Eleven patient records were reviewed on July 29 to 30, 2013. One patient record required notifying the referring narcotic treatment program of the admission and initial dose of the patient, # 11.
Patient record # 11 documented a transfer from a narcotic treatment program on 5/23/2013. The record contained a completed notification form that included the admission date and initial dose. The record did not include verification of the form having been sent to the referring narcotic treatment program and a consent to release the information was not documented in the record.
The findings were reviewed and confirmed with the Facility Director.
|
Plan of Correction
The Executive Director shall complete an in-service with the intake staff of the facility by 8/23/13 to educate staff on the need to document the notification to a referring facility of the admission and initial dosing of the patient at the time of intake to our facility. A handout on the procedure will be given the intake staff during the in-service. During intake, a dose verification sheet will be completed and faxed, the fax confirmation sheet will be filed in the chart as evidence of completion and the process will be completed by the intake worker at the intake assessment. The dose verification, the ROI to the referring Provider and the Fax cover sheet will all be added to the intake package as of 8/2/13 by the executive director to prompt the completion of this process. As of 8/2/13 a modified audit sheet has been completed to include the fax confirmation sheets by the Executive Director. New admissions will be audited monthly by the Program Manager, and Executive Director to ensure completion |
715.23(b)(22) LICENSURE Patient records
(b) Each patient file shall include the following information:
(22) Aftercare plan, if applicable.
|
Observations
Based on the review of patient records, the facility failed to document an aftercare plan based on the status of the patient at discharge in 3 of 3 patient records reviewed.
The findings include:
Eleven patient records were reviewed on July 29 to 30, 2013. Three patient records required an aftercare plan. The aftercare plans were not updated at the time of discharge of the patient, # 4, 6 and 7.
Patient record # 4 documented an admission date to the narcotic treatment program on 9/5/2012. An aftercare plan was begun at admission. The patient record documented the patient was discharged involuntarily with a completed taper on 2/19/2013. The aftercare plan was not completed upon discharge after five months of treatment.
Patient record # 6 documented an admission date to the narcotic treatment program on 1/13/2011. An aftercare plan was begun at admission. The patient record documented the patient was transferred to another narcotic treatment program on 6/18/2013. The aftercare plan was not completed upon discharge after 1 1/2 years of treatment.
Patient record # 7 documented an admission date to the narcotic treatment program on 9/19/2012. An aftercare plan was begun at admission. The patient record documented the patient was discharged involuntarily with a completed taper on 2/19/2013. The aftercare plan was not completed upon discharge after five months in treatment.
The findings were reviewed and confirmed with the Facility Director.
|
Plan of Correction
The Executive Director will modify the current discharge paperwork package to include the aftercare form as this was not included previously. The Discharge paperwork package will now include the termination letter, a follow up letter, and the AMA discharge / Administrative Discharge paperwork and the aftercare form. The modified package shall be completed by 8/16/13. The executive Director will complete an In-service on the paperwork requirements for proper discharge by 8/30/13 and will introduce the full discharge package that a counselor will be required to complete. A hand out for completing the aftercare form will be given during this in service. All counselors will be required to complete this full d/c package for all discharges starting on 9/1/13 after the in-service is completed. Close out Audits on discharges will be completed by the Executive director and Program Director monthly on all discharges completed within that month. Any findings showing a failure to complete the updated aftercare form will be addressed in the counselor's supervision with the executive Director. |