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 25 through September 26, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, PA Care LLC d/b/a/ State College Medical, 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.
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Plan of Correction
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715.16(a)(3) LICENSURE Take-home privileges
(a) A narcotic treatment program shall determine whether a patient may be provided take-home medications.
(3) The narcotic treatment physician shall document in the patient record the rationale for permitting take-home medication.
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Observations
Based on the review of patient records, the facility failed to ensure the physician documented in the patient record the rationale for granting take home medication in six of six patient records.The findings include:Twelve patient records were reviewed on September 25-26, 2012. Six patient records were reviewed for take home medication documentation. Per regulation, the narcotic treatment physician shall document in the patient record the rationale for permitting take home medication. Patient records # 1, 2, 3, 9,11, and 12 did not have the physician's rationale for granting the take home medication.The finding was discussed with the narcotic treatment physician and the facility director September 25, 2012 and was not disputed.
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Plan of Correction
The medical director will be trained by facility director on the completion of take home privilege request forms. He will document his rationale for granting take home privileges to patients on the take home form. This will be reviewed by nursing staff when the form is given to them to enter the new order into the computer dosing system. In addition, the facility director will monitor the status of take homes and related forms.
Training with the physician will occur on 10/23/12
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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 and the facility policy and procedures, the facility failed to transfer the required patient files in one of one patient record.The findings include:Twelve patient records and the facility's policy and procedures were reviewed September 25-26, 2012. Based on the facility's policy, the facility will release the following information to the facility receiving the transferred patient: date of admission, psychosocial summary, drug and alcohol treatment history, personal history, psychosocial evaluation, case termination conference note, medical summary, medical history, most recent physical examination, TB test results, most recent blood serology test, urine labs for the past twelve months, current dose level and current dosing schedule. One patient record required the facility transfer specific patient files to the receiving narcotic treatment program as part of the transfer process. The facility failed to send the required information for patient record # 12. Patient # 12 was discharged as a transfer to another narcotic treatment facility on June 7, 2012. The facility failed to send the patient's psychosocial summary, drug and alcohol treatment history, personal history, psychosocial evaluation, medical summary, medical history, most recent physical examination, TB test results, and most recent blood serology test, as required by the facility's policy and procedures.This finding was reviewed with the facility director and was not disputed.
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Plan of Correction
The facility director will review the process for transfers in/out of the program with clincal staff. This will occur on or before 10/20/12
The transfer in/out checklist will be reviewed with clinical staff at this time.
The clinical staff will be reminded of the importance of sending ALL required documents to a transfer facility.
The facility director will monitor the clinical staff regarding this issue on an ongoing basis.
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715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
Based on the review of patient records, the facility failed to complete all required laboratory tests as part of the admission process in two of twelve patient records reviewed. The findings include:Twelve patient records were reviewed September 25-26, 2012. All patient records were reviewed for completed laboratory tests as part of the admission process, specifically a tuberculosis Mantoux test (PPD) and Syphilis (RPR) Testing. Patient # 7 was admitted on January 20, 2012. The facility received documentation of a PPD and RPR testing that was completed in November of 2008. The facility failed to repeat the tests as a part of the admission process. Patient # 10 was admitted on May 8, 2012. The facility failed to obtain a PPD test as part of the admission process.This finding was reviewed with the facility director and was not disputed.
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Plan of Correction
Effective 9/27/12, TB & RPR will be run on all new patients by medical staff, including transfers. The only exception will be if a transfering patient presents recent TB/RPR results to the facility upon intake. Medical staff was trained on this implementation on 9/27/12.
In addition, PPD and RPR testing has been completed on Patient #7, and PPD has been completed on Patient #10.
The facility director will monitor this on an ongoing basis. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on the review of client records, the facility failed to give the patient an opportunity to request reconsideration of a decision terminating treatment. The findings include:Twelve patient records were reviewed on September 25-26, 2012. The project was required to give the patient an opportunity to request reconsideration of a decision terminating treatment in one patient record. The project did not document that the patient was given an opportunity to request reconsideration of the termination in patient record # 7.This finding was discussed with the facility director and was not disputed.
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Plan of Correction
Effective 9/27/12, the facility began using an adminstrative discharge letter which included providing the pateint an opportunity to request reconsideration of the decision.
The facility director reviewed this form with clinical staff of 9/27/12, and will monitor clinical staff to be sure that the correct letter is provided to patients when the decision to terminate is made. |