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 April 22-24, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Narcotic Addict Rehabilitation Program of Thomas Jefferson University was found not to be in compliance with the applicable chapters of 4 PA Code and 28 PA Code which pertain to the facility.
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Plan of Correction
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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.
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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 two of two patient records reviewed.
The findings include:
Eleven patient records were reviewed April 22-24, 2014. Two patient records were reviewed for documentation of notification to the referring facility of the admission date and date of first dose of the referred patient. There must also be a consent to release information signed by the patient prior to the contact.
Patient # 9 was referred and admitted to the facility on February 18, 2014. There was no documentation of the referring facility having been contacted, nor was there a consent signed by the patient for the release of information to the referring facility.
Patient # 11 was referred and admitted to the facility on March 13, 2014. There was no documentation of the referring facility having been contacted, nor was there a consent signed by the patient for the release of information to the referring facility.
This was discussed with facility staff on April 24, 2014.
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Plan of Correction
The intake coordinator will include a release of information for the referring facility in each admission packet for patients admitted via transfer and explain to the patient that the purpose of signing the release is to inform the referring facility of the patient's admission and first dose. Once the release is signed, the first dose is administered, and the admission is complete, the intake coordinator will contact the referring facility by phone to inform them of the patient's admission and initial dose. The intake coordinator will document the contact with the referring facility in the initial admission progress note, which is completed on the day of admission. The release of information and the documentation of contact with the referring facility will be added to the admission checklist and reviewed by the Senior Therapist for completion. |
715.21 LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
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Observations
Based on the review of administrative and patient record documentation, the facility failed to ensure all efforts to retain the patient were initiated before initiating termination of the patient in one of three patient records reviewed.
The findings include:
Eleven patient records were reviewed April 22-24, 2014. Three patient records were reviewed for involuntary termination documentation.
Patient # 9 was admitted February 18, 2014. The clinical notes and nursing notes reflected the patient was struggling to attend scheduled services on a regular basis. On April 1, 2014, the patient was given a notice of intent to involuntarily terminate the patient for not attending individual counseling sessions; not keeping appointments with the facilty physician and having positive results from urine drug screens. The patient's involuntary termination detoxification was initiated on the same date without benefit of an opportunity to appeal. In addition, the documentation did not reflect any efforts to work with the patient other than having her meet with the clinical supervisor where she was told what she must do to be compliant. Other measures were not implemented prior to the start of the detoxification.
This was discussed with the administrative staff April 23, 2014.
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Plan of Correction
Involuntary terminations will be instituted only in those instances when all other efforts at engagement have failed. Clinical staff have been informed of this via training and supervision conducted by the Senior Therapist and Program Coordinator. To ensure compliance with the standard, all episodes of involuntary termination are now reviewed by the Senior Therapist and/or Program Coordinator to ensure that satisfactory efforts at engagement have been made and documented in the clinical record. The Notice of Involuntary Treatment Termination has been revised to advise the patient of their right to appeal. |