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 February 25-27, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Dolminis 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 and a plan of correction is due on March 31, 2009.
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Plan of Correction
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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
Based on the review of patient records, the facility failed to maintain the confidentiality in four of four patient records reviewed.The findings include:Eleven patient records were reviewed on February 26 and 27, 2009. Confidentiality was reviewed in four patient records. Patient records # 5, 6 and 11 contained consents to obtain information from rather then consents to release information to funding entities. Patient record # 7 contained a consent to release drug test results to the county children and youth services program.
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Plan of Correction
A re-training on the completion of consents was conducted on March 4, 2009 and reviewed again on March 11, 2009. Also, a release of information "cheat sheet" taken from the policy and procedure manual was given to all staff for quick reference.
Program Director and lead counselor will monitor during weekly/monthly chart reviews. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on the review of patient records, the facility failed to ensure that all required drug screens were completed in one of seven patient records reviewed. The findings include: Eleven patient records were reviewed on February 26 and 27, 2009. Seven patient records were reviewed for drug screening urinalysis results. Patient # 4 did not have a urinalysis completed in January 2009.
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Plan of Correction
Client's urine screen was not requested on January 1, due to the holiday. Data requesting clients screen be generated on another day was not entered into the system. All urine screens will be requested on the day they are randomly generated by the computer software system regardless of the day they are generated. If the client is not on site the day the urine screen is requested the nurse on duty is responsible for aknowledging the request and manually entering a new date into the system. This new date is to be the next scheduled day the ct. is to be on site.
This will be monitored during weekly/monthly chart reviews conducted by the lead nurse, program director and lead counselor. |
715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on the review of patient records, the facility failed to document what materials were sent to the receiving program in two of two patient records reviewed. The findings include:Eleven patient records were reviewed on February 26-27, 2009. Two patient records were required to contain documentation of what materials were sent to the receiving program. Patient records # 2 and 5 did not have the materials sent documented as required.
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Plan of Correction
A check-off form to document any and all material(s)released to receiving programs is being developed and will be implemented by 3/23/09. All staff will be trained on the use of this form prior to implementation.
Program director and/or lead counselor will monitor monthly/weekly during routine chart reviews. |