INITIAL COMMENTS
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This report is a result of a plan of correction follow up inspection conducted for the approval to use a narcotic agent, specifically methadone, in the treatment of narcotic addiction. This inspection was conducted on February 4, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center For Behavioral Health - Farrell, 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 4, 2011.
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Plan of Correction
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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 a review of patient records, the narcotic treatment program failed to document what materials were sent to the receiving narcotic treatment program in three of four patient records.
The findings include:
Fourteen patient records were reviewed on February 4, 2011. Four records are required to have documentation of the materials sent to the receiving provider for the patients transfer. In patient records #12, 13 and 14 there was no documentation of the materials sent to the receiving narcotic treatment program.
This was discussed and confirmed with the director on February 4, 2011.
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Plan of Correction
The clinical supervisor held and inservie on February 24, 2011 to inform staff of proper documentation need when a patient transfers to another facility. Staff informed that transfer paperwork needs to be filed with the fax transmittal form and filed in patients chart whenever a patient transfers to another facility. The staff was also instructed to complete a General Note stating that the paperwork was faxed. The will be monitored by the clinical supervisor and senior counselor through chart audits for compliance |
715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on review of the patient records, the facility failed to document that the initial intake physical examination was completed prior to the first medication dose in one of eight patient records.
The findings include:
Fourteen patient records were reviewed on February 4, 2011. Eight patient records were required to include documentation of the results of an initial intake physical examination. One of the eight patient records reviewed did not have a physical examination completed prior to the first medication dose.
Patient record #5 was admitted on December 16, 2010. The physical examination was completed and signed by the physician on December 17, 2010. The initial dose of methadone was given on December 16, 2010, prior to the signature of the physician on the physical examination.
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Plan of Correction
The program director spoke with the Medical Director and physician assistant on February 23, 2011 explaining that all initial physicals need to be documented on the the day of admission and if it can not be entered into the electronic chart that day the hard copy signed by the medical director the day of admission will be filed the the patient chart. The program director will do sporadic checks on new admissions to monitor complianc |
715.29(4) 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.
(4) The narcotic treatment program shall maintain documentation of the Department 's approval of an exception.
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Observations
Based on observation of the dosing area and facility policy and procedures, the facility failed to follow the requirements of an exception granted by the Division of Drug and Alcohol Program Licensing.
The findings include:
An exception dated November 6, 2006 permitted oral swabs to be used for drug screening urinalysis for patients with medical problems that precluded their ability to void urine on demand. The facility's dosing area was observed on July 9, 2010 from approximately 9:00 AM to 9:30 AM. During the observation of the dosing area, a patient stated that he was unable to provide a urine sample. The patient was then given an oral swab test.
During an interview with the facility director, clinical supervisor and the nurse manager on July 9, 2010, it was confirmed that the facility did not have medical documentation that the patient had a medical problem that precluded their ability to void urine on demand. The nurse manager stated that the patient has medical problems that preclude the patient from voiding urine on demand, but the patient has not provided medical documentation to the facility.
Fourteen patient records were reviewed, and none of the patient records reviewed met the conditions established to utilize the oral swab instead of the urinalysis. The facility should re-submit the original plan of correction.
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Plan of Correction
The Program Director and Nurse Manager met with nursing staff on Feb 24,2011 to go over the exception on oral swabs. Nurses were informed that oral swabs can only be done on patient with medical documentation in their file stating they can not void urine and need to be swabbed. The program director and nurse manager will be monitor the specimens for compliance |