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 and buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on April 15-16, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Family Center 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(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 the required patient files in two of two patient records.
The findings include:
Ten patient records were reviewed April 15-16, 2014. The facility was required to transfer two patient files to the receiving narcotic treatment program as part of the transfer process. Patient records # 1 and 4 did not contain documentation of the transfer of the specified files.
Patient # 1 was discharged as a transfer to another narcotic treatment facility on February 21, 2014. There was no documentation of the required patient files being transferred to the receiving facility.
Patient # 4 was discharged as a transfer to another narcotic treatment facility on March 4, 2014. There was no documentation of the required patient files being transferred to the receiving facility.
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Plan of Correction
The plan of correction will include a cover sheet, with the intake admission packet, which includes a list of all regulatory documentation required for transfer to the receiving facility from the transferring facility. The cover sheet will be signed-off by the Aministrative Clinic Coordinator and kept in the chart in the "Assessment" section. Regulatory documents for transfer to another facility will be part of the Patient's Discharge Packet. Random quarterly chart checks by the Clinic Director will provide monitoring for compliance. Review of closed/transferred patient charts will be screened for compliance by the Clinic Director.
Person(s) Responsible: Clinic Director and Administrative Clinic Coordinator.
Timeframe for completion: 4/23/14 |
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
Based on the review of patient records, the facility failed to ensure compliance with the conditions of an exception granted by the Division, regarding thirteen day take-home privileges, in two of two patient records.
The findings include:
Patients with an approved exception for thirteen day take-home privilege status must have quarterly call backs. Call backs are an unscheduled return by the patient to the facility within 24 hours of being notified. The call back includes taking an inventory of the patient's remaining take home supply, drug testing or methadone plasma levels, and a review as to whether the reduced take-home schedule should continue.
Ten patient records were reviewed April 15-16, 2014. Two patient records required compliance with the conditions of the exception for thirteen day take-home privileges. The facility failed to comply with the Department approved exception in patient records # 5 and 6.
Patient # 5 was admitted on March 29, 2002. The patient has an exception to receive 13 take home medication bottles. A quarterly review was conducted for only three of four quarters during 2013. Reviews were conducted on February 22, 2013, May 23, 2013 and August 26, 2013. There was no review as to whether the reduced take-home schedule should continue.
Patient # 6 was admitted June 19, 2000. The patient has an exception to receive 13 take home medication bottles. A quarterly review was conducted for only three of four quarters during 2013. Reviews were conducted on February 2, 2013, April 30, 2013 and August 19, 2013. There was no review as to whether the reduced take-home schedule should continue.
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Plan of Correction
The Nurse Coordinator will engage the nurses to include quarterly call-backs into the AMS. The nurses to be the front line checkpoiont for call-back compliance. The second checkpoint will be the Clinic Director monitoring all 13 days THB call-backs on a quarterly basis during supervision with the Primary Counselors for compliance.
Person(s) Responsible: Nurse Coordinator, Nurses, Clinic Director, Primary Counselor
Timeframe for completion: 4/23/2014 |