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 February 6-8, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House-PA 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
|
715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
|
Observations
Based on a review of patient records, the facility failed to document that it transferred patient records in two of seven patient records.
The findings include:
Twenty seven patient records were reviewed on February 6-8, 2012. Seven of the patients reviewed transferred to another narcotic treatment facility and required a transfer of patient records. There was no documentation that the facility transferred the required documentation in patient records # 23 and 24.
Patient # 23 was admitted on April 6, 2011 and transferred to another narcotic treatment program on August 5, 2011. There was no documentation that the the facility transferred the required patient records to the new facility.
Patient # 24 was admitted on April 8, 2010 and transferred to another narcotic treatment program on August 16, 2011. There was no documentation that the facility transferred the required patient records to the new facility.
The facility director and clinical supervisor were interviewed on February 8, 2012 and confirmed the findings.
|
Plan of Correction
Copies of all patient-transfer documentation will be kept in the patient's chart upon transfer to another facility. This will be immediate and on-going. An in-service training on transferring a patient will also be held on 3/5/12. Our Clinical Supervisor will conduct this training, which will include how to transfer a patient, what to document and what to send to the receiving clinic. We will also cover the necessity of keeping a copy of the documentation in the patient's chart of what was sent and when. Clinical Supervisor will monitor for compliance. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
|
Observations
Based on the review of patient records, the facility failed to document follow-up information regarding the patient in four of twelve patient records.
The findings include:
Twenty seven patient records were reviewed on February 6-8, 2012. Twelve patient records were reviewed as discharged patients. Twelve patient records required follow-up information. Per policy, follow-up is to be completed at 14 and 30 days. The facility did not document follow-ups per policy in patient records # 11, 14, 15 and 23.
Patient # 11 was admitted on September 14, 2005 and discharged on October 25, 2011. Follow-up information was to be on completed November 8 and November 24, 2011. The two documented follow-ups were dated November 29, 2011.
Patient # 14 was admitted on May 7, 2009 and discharged on November 8, 2011. Follow-up information was to be completed on November 22 and December 8, 2011. The two documented follow-ups were dated November 29, 2011.
Patient # 15 was admitted on December 9, 2009 and discharged on October 25, 2011. Follow-up information was to be completed on November 8 and November 24, 2011. The two documented follow-ups were dated November 18, 2011.
Patient # 23 was admitted on April 6, 2011 and discharged on August 5, 2011. Follow-up information was to be completed on August 19 and September 4, 2011. There was no documentation that the September 4, 2011 follow-up was completed.
The facility director and clinical supervisor were interviewed on February 8, 2012 and confirmed the findings.
|
Plan of Correction
All discharged patients will receive a follow-up letter at 14 and 30 days after discharge without exception. This will be immediate and on-going. An in-service training on our follow-up policy will also be conducted on 3/5/12. Our clinical supervisor will conduct the training, which will cover how and when to send follow-ups to our discharged patients. Clinical Supervisor will monitor for compliance. |