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 8 - 10, 2011 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 and a plan of correction is due on April 11, 2011.
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Plan of Correction
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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.
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Observations
Based on the review of patient records, the facility failed to contact the previous narcotic treatment facility for the patient's treatment history in three of four patient records reviewed.
The findings include:
Thirty three patient records were reviewed March 8-10, 2011. Four patient records were required to contact the prior narcotic treatment facility for the previous treatment history. One patient record included documentation that an attempt was made. Three patient records, #7, #21 and #28, did not include documentation that an attempt was made.
This was discussed with the clinical director on March 9 and 10, 2011. The clinical director confirmed that the attempt to contact the previous narcotic treatment facility for the treatment history was not completed.
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Plan of Correction
Effective immediately, the clinical director will ensure that applicants sign the necessary consent forms to obtain treatment information from other NTP's when applicable. Documentation will be in the client file. |
715.23(b)(22) LICENSURE Patient records
(b) Each patient file shall include the following information:
(22) Aftercare plan, if applicable.
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Observations
Based on a review of the facility policy, patient records and an interview with the clinical director, the facility failed to complete an aftercare plan in three of five patient records.
The findings include:
The facility policy was reviewed on March 8, 2011, and states an aftercare plan will be completed for all successful discharges.
Thirty three patient records were reviewed on March 8-10, 2011. Five were required to include documentation of an aftercare plan. Three patient records, #17, #19, and #33, did not include documentation of an aftercare plan.
This was discussed with the clinical director on March 9 and 10, 2011. The clinical director confirmed that aftercare plans have not been completed for the identified records.
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Plan of Correction
Effective immediately, clinical director will instruct all counselors to formulate aftercare plans when applicalbe for clients leaving the program |