INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and 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 October 3-4, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Tadiso Inc was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility failed to document that a written unusual incident report was submitted to the Department within 3 business days following an incident involving the presence of police and ambulance at the facility.
A unusual incident report dated 3/2/16 documented that the police and an ambulance were called to facility parking lot. There was no documentation that the report was sent to the Department as of October 4, 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff members have been instructed to notify the Operations Director, if and when the emergency personnel need to be called. Emergency personnel include fire department, police officers, and ambulance personnel. In the event the Operations Director is not available at the facility, she will be notified the next business day. The Operations Director is responsible for completing and sending the Unusual Incident Report to the Department. A log will be maintained of all reports sent to the Department and will include the fax transmittal verification. |
715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
The facility failed to physically secure and maintain the confidentiality of patient records in accordance with 42 CFR Part 2, Subpart B, 2.22 (relating to notice to patients of Federal confidentiality requirements) and 28 Pa. Code 709.28 (relating to confidentiality).
During the observation of methadone dispensing on October 4, 2016, the patients were observed returning their take home bottles to the nurse. The nurse then placed the bottles in a trash can. The names were not blacked out. The nurse was then asked what happens to the bottles. The take home bottles in the cans at the nurses stations are then placed in a larger trash bin. The bin was observed and upon removing take home bottles from the trash can, the patient first and last names were clearly visible on the bottles. The maintenance department is then responsible for removing the take home bottles from the bin and re packing them for shipment and disposal. This practice failed to maintain the confidentiality of the patients with take-home privileges.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The nurses will dispose of the bottles in the medical waste bags. The nurse is responsible for tying and taping the bag closed. The nurse is responsible for taking the medical waste to the designated pickup location. The Nursing Supervisor will ensure completion of these tasks. Tadiso will be in full compliance with this standard, effective today, October 20, 2016. |
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
The facility failed to document, in writing that it notified the transferring narcotic treatment program of the date of the initial dose given to the patient by the receiving narcotic treatment program in two of two patient records reviewed on October 3-4, 2016.
Twelve patient records were reviewed as methadone patient records. Two records were reviewed as transfer in patients. The facility failed to notify the transferring facility of the date of the initial dose given to the patient by the receiving narcotic treatment program in patient records # 4 and 5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has corrected the Verification of Transfer Form, to reflect the date of first dosage at Tadiso. The Clinical Supervisors have been trained on the proper completion of the form and on the faxing of the form. The form is scanned in to the electronic health record along with the fax transmittal verification. The Director of Social Service is responsible for overseeing completion of this task. Tadiso became in full compliance with this standard on October 11, 2016. |
715.29(5) LICENSURE Exceptions
A narcotic treatment program is permitted, at the time of application or any time thereafter, to request an exception from a specific regulation.
(5) If the exception relates to a specific patient, the narcotic treatment program shall maintain documentation of the exception in the patient 's record.
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Observations
The facility failed to maintain documentation of an exception in a patient 's record in one of one record reviewed on October 3-4, 2016.
Twelve patient records were reviewed on October 3-4, 2016. All twelve were reviewed as methadone patient records. One patient was reviewed as an exception for take home medication bottles. The facility did not maintain documentation of an exception for 6 day take home bottles in patient record # 1.
Patient # 1 was admitted on March 22, 2016. She was given 6 day take home bottles on July 22, 2016. The patient did not meet the criteria for 6 day take home bottles. There was no documentation of exception for the 6 day take homes.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All physicians have been instructed to clearly document the rationale for providing medical exceptions for take home medication in the patient record. This includes a description of the medical need for this exception. This will also be written as a physician ORDER. The Nursing Supervisor is responsible for overseeing this task. The effective date that Tadiso became in compliance with this standard is October 11, 2016. |