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.
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Observations
Based on the review of patient records, the facility failed to transfer patient files which is to include the patient ' s admission date, medical and psychosocial summaries, dosage level, urinalysis reports, exception requests and current status of the patient in one of three patient records.
The findings include:
Sixteen patient records were reviewed on January 20 - 21, 2015. Three records pertained to patients that transferred to another narcotic treatment program. The facility was required to document the transfer of specific patient files to the receiving narcotic treatment program as a part of the transfer process. The facility failed to transfer patient ' s file which included the admission date, medical and psychosocial summaries, dosage level, urinalysis reports, exception requests and current status of the patient in patient record #3.
Patient # 3 was admitted into treatment on September 16, 2014 and transferred to another narcotic treatment program on January 7, 2015. There was no documentation showing that the patient ' s file was transferred to the receiving facility, as of January 20, 2015.
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Plan of Correction
The Clinical Supervisor is responsible to ensure that all documentation is sent to transferring facilities and that the sending of the documentation is documented. In order to obtain compliance all staff will be instructed by the clinical supervisor in a meeting to send all of the required documents via fax to all transferring facilities and retain the fax transmittal verification to be filed in the clinical record to document that the documents were sent. In order to ensure continued compliance all discharge charts will be audited to verify that the documentation has been sent and documented. |