INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on October 23-25, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Division of Accountability and Program Improvement. 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. The following deficiencies were identified during this inspection.
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Plan of Correction
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709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
The facility failed to document that verbal orders were authenticated by the physician within 3 business days in one of one client record reviewed on October 23-25, 2018.
Client record # 7 a verbal order was documented on August 6, 2018. The physician's signature was dated August 16, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The physician will review and sign all verbal orders within 3 days of the order being written. The physician is responsible for completing this task within 3 days. The Director of Medical Services is responsible for ensuring the completion and compliance of this task. Tadiso will be in full compliance with this standard effective 11/20/2018. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
The facility failed to document that the client was notified, in writing, of a decision to involuntarily terminate the client 's treatment at the project in one of three client records reviewed on October 23-25, 2018.
Client # 15 was involuntarily terminated. There was no documentation that the client was given written notice of the termination.
Thee findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The patient will be given a written termination letter, when he is discharged from the program. The letter will include the right to appeal the decision and the steps for the appeal process. The Social Service Director is responsible for preparing the termination letter. The Program Director is responsible for compliance with this standard. Tadiso will be in full compliance with this standard effective 11/20/2018. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
The facility failed to document that the client was given the opportunity to request reconsideration of a decision to terminate treatment in one of three client records reviewed on October 23-25, 2018.
Client # 15 was involuntarily terminated. There was no documentation that the client was given the opportunity to request reconsideration.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The patient will be given a written termination letter, when he is discharged from the program. The letter will include the right to appeal the decision and the steps for the appeal process. The Social Service Director is responsible for preparing the termination letter. The Program Director is responsible for compliance with this standard. Tadiso will be in full compliance with this standard effective 11/20/2018.
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715.9(a) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
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Observations
The facility failed to verify the individual had reached the age of 18, the individual's identity, which included the individual's name, date of birth and other identifying information in one of seven client records reviewed on October 23-25, 2018.
Client record # 17 was missing the verification of age and identity.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
It was brought to our attention on 10/25/2018 that a patient file was missing the verification of age and identity (I.D.). After further review, it was not able to be located. The corrective action to this citation was to add a service to the electronic health record that would allow a counselor, supervisor, or quality assurance personnel to confirm an ID had been verified at intake. Once it was determined the ID was submitted, the electronic service would be signed off on by either a fiscal staff member or a social service staff member. This plan will be in effect on 11/27/2018. The Director of Social Service as well as Quality Assurance will be responsible for ensuring that all ID's are verified as received for all admissions. |
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
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Observations
The facility failed to document that the narcotic treatment physician consulted with the Certified Nurse Practioner, who performed the examination, before determining the patient 's initial dose in three of eight patient records reviewed on October 23-25, 2018.
Patient records # 1, 2 and 3 did not have documentation that the physician ordering the patient's initial dose consulted with the Certified Nurse Practioner, who completed the physical exam, prior to the patient's initial dose.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On October 25, 2018 it was determined that the physician ordering the patient's initial dose did not consult with the CRNP who completed the physical exam, prior to the patient's initial dosage. It was determined that an additional medical note would need to be written verifying the CRNP and the medical doctor consulted, prior to the medical doctor submitting the order for the patient's initial dose of medication. On 10/31/2018, a meeting was held with the Medical Director and the Director of Medical Services in which the CAO, Operations Director, Policy Specialist and Director of Social Service were present. It was advised at this time that it would be necessary to document a consult with the CRNP and the physician prior to the patient receiving their initial dose of medication. The Director of Medical Services will be responsible for making sure that files accurately reflect the CRNP and the medical doctor have met regarding these consultations. This plan has gone into effect 11/26/2018. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
The facility failed to document an annual physical examination in one of five patient records reviewed on October 23-25, 2018.
Patient record # 8 was missing an annual physical examination due to be conducted by December 31, 2017.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
It was determined on 10/25/2018 during our annual licensing audit that an annual physical examination was missing, and was to be completed by 12/31/2017. It was not found in the electronic health record. A meeting has held on 10/31/2018 with the Medical Director and the Director of Medical Services in which the CAO, Operations Director, Policy Specialist and Director of Social Service were present. It was determined that the Director of Medical Services would assist the physician with scheduling, and ensuring that all documentation regarding required medical services were completed on or before the date due. The Director of Medical Services and Quality Assurance will continue to internally audit all files to ensure that no documentation is incomplete, missing, or late. This plan will go into effect no later than 11/26/2018. |