This report is a result of an on-site licensure renewal inspection and inspection conducted for the approval to use a narcotic agent, specifically methadone, in the treatment of narcotic addiction. This inspection was conducted on October 14-15, 2014, by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the findings of the on-site inspection, Center for Behavioral Health -HA. Inc, 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:
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Plan of Correction
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Observations
Based on the review of patient records, the facility failed to document that it notified, in writing, 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 in three of five patient records.
The findings include:
Seventeen patient records were reviewed on October 14-15, 2014. Five patient records reviewed had transferred in from another narcotic treatment program. The facility did not document that it notified the transferring program of the admission of the patient and the date of the initial dose given to the patient in patient records # 2, 6 and 7.
Patient # 2 had transferred from a narcotic treatment program and was admitted on February 7, 2014. There was no documentation that the transferring program had been notified , in writing, of the admission of the patient and the date of the initial dose given to the patient.
Patient # 6 had transferred from a narcotic treatment program and was admitted on April 15, 2014. There was no documentation that the transferring program had been notified, in writing, of the admission of the patient and the date of the initial dose given to the patient.
Patient # 7 had transferred from a narcotic treatment program and was admitted on August 28, 2014. There was no documentation that the transferring program had been notified, in writing, of the admission of the patient and the date of the initial dose given to the patient.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director met with members of the Management Team to review the Division of Drug and Alcohol Program Licensure citation received during the licensing inspection. The Program Manager and the Clinical Supervisors will be responsible for following 715.20(4) Licensure standards for patient transfers.
The Program Director met with members of the Management Team to review the Division of Drug and Alcohol Program Licensure citation received during the licensing inspection. The Program Manager and the Clinical Supervisors will be responsible for following 715.20(4) Licensure standards for patient transfers.
The Program Manager and the Clinical Supervisors will ensure that when a patient transfers into our facility we will notify, in writing, the transferring facility, the patient's admission date and date of initial dose.
The Program Director will ensure that the Plan of Correction is followed and the proper information is documented in the patient's file.
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