INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on November 12-14, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Family Center of Thomas Jefferson University (MATER) 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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715.20(1) 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.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
Based on a review of patient records, the facility failed to transfer a patient file to another narcotic treatment program in one of two patient records reviewed.
The findings include:
Two patient records requiring documentation that the patient files were transferred to another narcotic treatment program were reviewed from November 12, 2014 to November 14, 2014. The facility failed to provide documentation that they transferred a patient file to another narcotic treatment program in patient record # 14.
Patient # 14 was admitted July 30, 2012 and discharged August 15, 2014 as a transfer to another narcotic treatment facility. However, patient record # 14 did not include documentation that the patient file was transferred to the receiving narcotic treatment facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A documented staff training will be conducted to remind staff to document all attempts to transfer a patient's file to an out-of-state clinic that is not under the DDAP Methadone regulations. The documentation will include the date, time, name of staff, number of attempts, and clinic name. "The Primary Therapist of Patient # 14 will transfer or attempt to transfer Patient # 14's file to the other narcotic treatment facility and document this information in Patient # 14's chart."Person(s) responsible will be the Clinic Supervisor/Director, Primary Therapist (Lead). Time frame for completion will be 12/11/14. |
711.94(b) LICENSURE Display Hours of Operation
711.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on observations on November 14, 2014, the facility failed to display conspicuously the hours of project operation to the general public.
The findings include:
A physical plant inspection was conducted on November 14, 2014. It was observed during the inspection at approximately 8:35 A.M. that the facility did not have the hours of project operation displayed conspicuously to the general public.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The hours of project operation was immediately corrected and displayed in the lobby of the facility after the physical plant inspection. The staff responsible, Clinic Director and Receptionist, will monitor quarterly to ensure the hours remain posted. When future renovations are completed the sign indicating the facility hours will be checked, by the Clinic Director, to ensure this notice is reposted . Time frame for completion was immediate. |