Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection and a complaint investigation, conducted on October 14, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated on-site inspection, Charleroi Treatment Services, Llc was found not to be in compliance with the applicable chapters of 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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Observations
The facility failed to 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 in two of four records. Patients # 2 and 3 did not document that the receiving narcotic treatment program was notified of the admission of the patient and the date of the initial dose given to the patient. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon entering into facility, a staff member completes a ROI form to transferring clinic. At this time information can then be discussed between the two facilities. Our LPN will provide the actual date of transfer and verify the date and amount of the patients first dose at our facility. This is then documented on paper with signatures, signed off on and sent to transferring clinic. This document is scanned into patient's chart for record.
This process had been discussed in a treatment team meeting held in office on 10-23-20. The form was handed out to all nursing staff, and reviewed in detail. Our nursing staff is responsible for implementing this process ASAP, and current Nurse Practitioner is responsible in reviewing this process has been completed. This documentation process was put into effect on 10-23-2020.
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