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 September 14, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Soar Corporation Chester was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and a plan of correction is due on October 8, 2010.
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Plan of Correction
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715.18(a)(1) LICENSURE Rehabilitative services
(a) A narcotic treatment program shall provide, either onsite or through referral agreements, a full range of rehabilitative services. Rehabilitative services shall include:
(1) HIV education services.
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Observations
Based on a review of policy and procedure, administrative documentation and a staff interview, the facility failed to provide documentation of rehabilitative services that included HIV education available to patients.
The findings include:
The facility policy and procedure and other administrative documents were reviewed on September 14, 2010. The facility failed to provide documentation that they had secured
HIV education services. In a staff interview it was identified that staff were unable to provide
verification that this rehabilitative service had been arranged for the facility's patients.
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Plan of Correction
Agency in Delaware County will be contacted and a referral agreement engaged. Form will be used that will cover HIV information that ct will sign at time of admission. Program Manager will contact agency and also make arrangements for inservice training on HIV education. Project Director will monitor for compliance. |
717.18(a)(2) LICENSURE Rehabilitative services
(a) A narcotic treatment program shall provide, either onsite or through referral agreements, a full range of rehabilitative services. Rehabilitative services shall include:
(2) Employment services.
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Observations
Based on a review of policy and procedure, administrative documentation and a staff interview, the facility failed to provide documentation of rehabilitative services that included employment services available to patients.
The findings include:
The facility policy and procedure and other administrative documents were reviewed on September 14, 2010. The facility failed to provide documentation that they had secured
employment services. In a staff interview it was identified that staff were unable to provide
verification that this rehabilitative service had been arranged for the facility's patients.
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Plan of Correction
Program Manager will contact local employment agencies to establish referral agreement so cts can be sent there for services related to employment. Program Director will monitor for compliance. |
715.18(a)(3) LICENSURE Rehabilitative services
(a) A narcotic treatment program shall provide, either onsite or through referral agreements, a full range of rehabilitative services. Rehabilitative services shall include:
(3) Adult educational services.
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Observations
Based on a review of policy and procedure, administrative documentation and a staff interview, the facility failed to provide documentation of rehabilitative services that included adult education services available to patients.
The findings include:
The facility policy and procedure and other administrative documents were reviewed on September 14, 2010. The facility failed to provide documentation that they had secured
adult education services. In a staff interview it was identified that staff were unable to provide
verification that this rehabilitative service had not been arranged for the facility's patients.
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Plan of Correction
Program Manager will contact local agencies for these services and establish a referral agreement with said agency. Program Director will monitor for compliance. |
715.18(a)(4) LICENSURE Rehabilitative services
a) A narcotic treatment program shall provide, either onsite or through referral agreements, a full range of rehabilitative services. Rehabilitative services shall include:
(4) Behavioral health services
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Observations
Based on a review of policy and procedure, administrative documentation and a staff interview, the facility failed to provide documentation of rehabilitative services that included behavioral health services available to patients.
The findings include:
The facility policy and procedure and other administrative documents were reviewed on September 14, 2010. The facility failed to provide documentation that they had secured
behavioral health services. In a staff interview it was identified that staff were unable to provide verification that this rehabilitative service had been arranged for the facility's patients.
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Plan of Correction
Program Manager will contact local agencies to establish referral agreements for these services. Program Director will monitor for compliance. |
715.20 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.
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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 3 of 4 patient records.
The findings include:
Four patient records were reviewed on September 14, 2010. Three patient records were reviewed for documentation of notification to the referring facility of the admission and dosing of the referred patient. Patient records # 1, 2 and 3 were referred by another narcotic treatment program and there was no documentation that the referral was notified of the admission and initial dosing of the patients.
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Plan of Correction
Form and letter developed and already in place to be used by staff regarding a ct transfer. Program Manager and Nurse charged with making sure that this form/letter is sent out to referring clinic. Program Director and Program Manager will monitor throughout the year for compliance. This will also become part of quarterly chart audit to ensure that one was done. |
715.26(b) LICENSURE Security
(b) Each narcotic treatment program shall provide the Department with a specific plan describing the efforts it will make to avoid disruption of the community by its patients and the actions it will take to assure responsiveness to the community. This plan shall designate a staff member to act as community liaison.
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Observations
Based on a review of administrative policy and procedure and staff interviews, the facility failed to document a plan describing the efforts it will make to avoid disruption of the community by its patients and the actions it will take to assure responsiveness to the community.
The findings include:
The administrative policy and procedure manual was reviewed on September 14, 2010. Per regulation, each narcotic treatment program shall provide the Department with a specific plan describing the efforts it will make to avoid disruption of the community by its patients and the actions it will take to assure responsiveness to the community. This plan shall designate a staff member to act as community liaison. The facility failed to provide documentation of a security policy that was specific to this site and the surrounding community.
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Plan of Correction
New plan will be developed by Tx Team, Program Manager and Program Director. Per regulation this plan will include all that is required. Program Manager designated to be community liason. Community issues to be added to QA/Health and Safety Committee agenda for quarterly meetings. Program Director will monitor for compliance throughout the year. |