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 June 22-23, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHJ Medical Center, Inc 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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Observations
Based on a review of patient records and an interview with the clinical supervisor, 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 three of three patient records.
The findings include:
Twenty patient records were reviewed on June 22-23, 2011. Three patients were transferred into treatment from a narcotic treatment program. Per regulation, 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. 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 in patient records # 2, 3 and 17.
Patient # 2 was transferred from a narcotic treatment program and admitted into treatment on May 17, 2011. There was no documentation that the facility notified the transferring narcotic treatment program of the date of the initial dose given to the patient.
Patient # 3 was transferred from a narcotic treatment program and admitted into treatment on December 21, 2010. There was no documentation that the facility notified the transferring narcotic treatment program of the date of the initial dose given to the patient.
Patient # 17 was transferred from a narcotic treatment program and admitted into treatment on May 19, 2011. There was no documentation that the facility notified the transferring narcotic treatment program of the date of the initial dose given to the patient.
The clinical supervisor was interviewed on June 22, 2011 at 9:30 A.M.. The clinical supervisor reviewed patient records # 2, 3 and 17 and confirmed there was no documentation that the transferring narcotic treatment program had been notified of the date of the initial dose given to the patient.
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Plan of Correction
The project director and nursing staff are responsibloe to ensure compliance with this regulation. In order to obtain and maintain compliance the project director will educate the nursing staff on the requirements of the regulation and instruct all nurses to document in thier nurses note the date of the clients initial dose at the facility following the initial dose when they call the transferring facilities to notify them of the completion date of the initial dose for transferring clients. The project director will then randomly audit transferring clients charts to ensure continued compliance. |