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 April 3-5, 2012 methadone monitoring inspection. The follow-up inspection was conducted on November 20, 2012 by staff from the the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Narcotic Addict Rehabilitation Program Of Thomas Jefferson University, 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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715.17(b) LICENSURE Medication control
(b) A narcotic treatment program shall develop policies and procedures regarding verbal medication orders, including the issuing and receiving of orders, identifying circumstances when orders are appropriate and documenting orders, in accordance with applicable Federal and State statutes and regulations.
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Observations
Based on the review of patient records, the facility failed to ensure the physician signed within 24 hours of the issued verbal order or dated the signature after issuing a verbal order in three of five patient records reviewed.
The findings include:
Ten patient records were reviewed November 20, 2012. Five patient records contained documentation of verbal orders issued by a physician.
Patient # 1 was admitted July 30, 2012. A verbal order was issued by a physician on October 30, 2012. The physician signed the verbal order, but the signature was not dated. Therefore it could not be determined it was signed within 24 hours as required.
Patient # 4 was admitted August 3, 2012. A verbal order was issued by a physician on August 10, 2012. The physician signed the verbal order, but the signature was not dated. Therefore it could not be determined it was signed within 24 hours as required.
Patient # 8 was admitted September 23, 2011. A verbal order was issued on October 29, 2012. The verbal order was signed by the physician November 2, 2012, more than 24 hours after it was issued.
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Plan of Correction
The Division Director has forwarded an exception request letter to the Director of Licensing. Specifically we are requesting a waiver to allow the physician to sign verbal orders the next time they are on-site. A response is awaited.
In the interim, it shall be the overall responsibility of the Division Director/Facility Director to ensure that program physicians sign verbal orders within 24 hours of their being issued. To accomplish this, the Head Nurse will compile and review orders to ensure they are signed and dated as required. |
715.23(b)(15) LICENSURE Patient records
(b) Each patient file shall include the following information:
(15) Psychosocial evaluations of the patient.
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Observations
Based on the review of patient records and administrative documentation, the facility failed to ensure the psychosocial evaluations were a clinical assessment of the historical data collected.
The findings include:
Ten patient records were reviewed November 20, 2012. Four patient records were reviewed for psychosocial evaluations.
Patient # 2 was admitted September 11, 2012. The psychosocial evaluation contained observational data that did not reflect a clinical assessment of the collected history.
Patient # 3 was admitted September 17, 2012. The psychosocial evaluation contained observational data that did not reflect a clinical assessment of the collected history.
Patient # 4 was admitted August 3, 2012. The psychosocial evaluation contained observational data that did not reflect a clinical assessment of the collected history.
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Plan of Correction
The Director of the Division of Substance Abuse Programs, along with other administrative personnel, have been meeting privately with clinical staff as part of a concerted effort to expand the clinical assessment recorded in the psychosocial evaluation. State requirements have been distributed and reviewed. Recent psychosocial efforts have been reviewed with staff and constructive feedback offered. This process will be ongoing. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on the review of patient records, the facility failed to document the attempt or completion of patient follow up contact in two of two patient records reviewed.
The findings include:
Ten patient records were reviewed November 20, 2012. Two patient records required documentation of an attempt or completion of a follow up contact.
Patient # 9 was admitted August 31, 2012. The patient was discharged September 14, 2012 as (AWOL) absent without leave. There was no documentation of any follow up attempt at the time of the inspection.
Patient # 10 was admitted August 31, 2012. The patient was discharged October 22, 2012 as (AWOL) absent without leave. There was no documentation of any follow up attempt at the time of the inspection.
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Plan of Correction
The Division Director has instructed the Certified Peer Specialist (CPS) on completion of post-discharge follow-up. A registry of contact efforts has been started. Completed follow-up contacts are filed in the clinical record. The Program Coordiantor will review the registry with the CPS on a monthly basis to ensure satisfactory compliance. |