Observations
Based on a review of patient records, the facility failed to provide, in writing, documentation 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 in one of one applicable records.
Patient #3 was transferred from another narcotic treatment program and admitted on January 2, 2024 and was still active at the time of the inspection. The patient ' s record did not have documentation that the facility notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Clinic Director and Clinical Supervisor will conduct an all staff meeting on 11/19/24 to thoroughly explain the procedures when admitting patient from another facility. We will identify all the required paperwork and documentation that is needed for a successful transfer and scan into the patient's chart. The primary counselor will then notify the Charge Nurse or dispensing nurse that a release has been completed and that medical staff can proceed with making contact with the referring narcotic treatment facility to confirm admission and dosage. This process will begin on 11/20/24 and will be monitored on a monthly basis during chart audit reviews completed by the Clinical Supervisor. |
Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every sixty days in four of seven applicable records reviewed.
Client #1 was admitted on January 10, 2024 and was discharged on June 26, 2024. A treatment plan update was completed on April 24, 2024 and the next update was due no later than June 24, 2024; however, the update was not completed prior to discharge.
Client #3 was admitted on January 2, 2024 and was still active at the time of the inspection. The facility had a Department-approved exception allowing this client ' s treatment plan updates to be completed every 120 days. A treatment plan update was completed on May 1, 2024 and the next update was due no later than September 1, 2024; however, the update was completed on September 4, 2024.
Client #5 was admitted on January 29, 2024 and was discharged on July 29, 2024. A treatment plan update was completed on March 26, 2024 and the next update was due no later than May 26, 2024; however, the update was completed on May 31, 2024.
Client #7 was admitted on August 6, 2009 and was still active at the time of the inspection. A treatment plan update was completed on June 3, 2024 and the next update was due no later than August 3, 2024; however, the update was completed on August 6, 2024.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Clinical Supervisor and Clinic Director will hold a staff meeting with counselors on 11/15/24 to discuss the importance of completing treatment plans timely within 60 days of the last treatment plan being completed and signed off by the counselor. We will identify that treatment plans are required to be done on the due date or sixty days from signing the prior treatment plan, to ensure that treatment plans are completed every sixty days. This will begin on 11/29/24 and monitored on a weekly basis by the Clinical Supervisor and the Lead Counselor prior to approval. |