INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection pertaining to the plans of correction for the July 27, 2011 methadone monitoring inspection. The follow-up inspection was conducted on January 4, 2011 by staff from the the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Discovery House, 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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715.20(4) 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.
(4) 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.
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Observations
Based on the review of patient records, the facility failed to document that it notified the referring facility of the admission and initial dosing of the patient in six of eight patient records.
The findings include:
Nineteen patient records were reviewed January 4, 2012. Eight patient records were transferred in from other narcotic treatment programs and required documentation of notification to the referring facility of the admission and initial dosing date of the referred patient.
The findings include:
Patient # 3 was admitted September 7, 2011. There was no documentation to show the referring facility had been notified of the patient's admission and initial dosing.
Patient # 5 was admitted November 14, 2011. There was no documentation to show the referring facility had been notified of the patient's admission and initial dosing.
Patient # 6 was admitted December 28, 2011. There was no documentation to show the referring facility had been notified of the patient's admission and initial dosing.
Patient # 7 was admitted November 14, 2011. There was no documentation to show the referring facility had been notified of the patient's admission and initial dosing.
Patient # 8 was admitted and there was no documentation to show the referring facility had been notified of the patient's admission and initial dosing.
This is a repeat citation from the methadone monitoring dated July 25-27, 2011.
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Plan of Correction
The Clinical Supervisor will re-educate the Admission Team on the regulation and process for documenting the notification to the referring facility of the admission and initial dosing of the patient.
The Admission Team will ensure the referring facility will be informed of an admission and the initial dose of a transferring patient and it is recorded in the medical record.
The Director will review the medical record of all patient's transferring into the facility to ensure there is notification and documentation of the transfer and initial dose. |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on the review and discussion with the facility director and the medical director, the facility failed to ensure the verbal orders were put in writing and signed within 24 hours by the prescribing physician.
The findings include:
Nineteen patient records were reviewed January 4, 2012. Eight patient records contained documentation of a physician's verbal orders. Eight patient records required the prescribing physician to sign within 24 hours of the verbal order. Seven patient records had documentation of verbal orders being signed by the prescribing physician more than 24 hours after the verbal order was given.
Patient record # 1 contained documentation of verbal orders being signed more than 24 hours after the verbal order was given. A verbal order given on 12/1/2011 was signed 12/4/2011. A verbal order given on 12/2/2011 was signed on 12/4/2011. A verbal order given on 12/29/2011 was signed on 1/1/2012.
Patient record # 2 contained documentation of a verbal order being signed more than 24 hours after the verbal order was given. A verbal order given on 10/24/2011 was signed 10/26/2011.
Patient record # 3 contained documentation of a verbal order being signed more than 24 hours after the verbal order was given. A verbal order given on 10/20/2011 was signed 10/23/2011.
Patient record # 9 contained documentation of a verbal order being signed more than 24 hours after the verbal order was given. A verbal order given on 12/30/2011 was signed 1/1/2012.
Patient record # 10 contained documentation of verbal orders being signed more than 24 hours after the verbal order was given. A verbal order given on 11/17/2011 was signed 11/20/2011. A verbal order given on 11/18/2011 was signed on 11/20/2011. A verbal order given on 11/24/2011 was signed on 11/27/2011.
Patient record # 13 contained documentation of verbal orders being signed more than 24 hours after the verbal order was given. A verbal order given on 11/3/2011 was signed 11/6/2011. A verbal order given on 11/18/2011 was signed on 11/20/2011. A verbal order given on 12/16/2011 was signed on 12/18/2011.
Patient record # 15 contained documentation of a verbal order being signed more than 24 hours after the verbal order was given. A verbal order given on 10/27/2011 was signed 11/2/2011.
A discussion of these findings with the facility and medical directors confirmed the physician was following the guidelines from the hospital and not signing within 24 hours as required by regulation.
This is a repeat citation from the methadone monitoring dated July 25-27, 2011.
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Plan of Correction
The Medical Director and Program Physician will sign all verbal orders within 24-hours.
The Nurse Manager will review the medical reports to ensure the orders are signed within 24-hours.
The MD's will ensure all verbal orders are signed within 24 hours begining Tuesday, January 17, 2012.
The Director is responible for ensuring the orders are signed within 24 hours. |