INITIAL COMMENTS
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This report identifies the findings of an on-site complaint investigation conducted on February 9, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on April 24, 2007.
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Plan of Correction
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709.62(c)(v) LICENSURE Physical Examination
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(5) Physical examination.
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Observations
Physical exams were not completed until after the initial methadone dosing in client records # 1 and #2. 28 Pa. Code Subsection 715.15(b) clearly stipulates that the physician determining the proper dosing level for a patient, including the initial dose, shall be the physician who conducted the patient examination or the dosing physician should have consulted with the physician who preformed the examination before determining the patient's initial dose and schedule. Dosing cannot occur until the physical examination has been completed.
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Plan of Correction
The nursing staff will be the check and balance of this system. They are not permitted to dose any patient without assuring that all necessary components are completed. Any questions, they will direct to their DON. A log sheet has been developed that includes columns indicating date/time when each component was completed. The dosing nurse will be responsible for reviewing and initialing the log prior to any first dose. All nurses will sign a memo outlining the proposed process. Weekly, the DON will review the Log Sheet to assure compliance. |
709.64(c)(1) LICENSURE Medical/dental support services
709.64. Project management services.
(c) The project shall assist the client in obtaining the following supportive services when necessary:
(1) Medical/dental.
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Observations
The facility failed to document that the patients represented by client records #1 and #2 had been given assistance in obtaining prenatal care by referral to appropriate health-care providers. 28 Pa. Code Subsection 715.10(b) and (c) clearly require that the patients be given an opportunity for such care.
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Plan of Correction
A log book has been created by the DON and started as of 4/5/07. This log book includes how many weeks patient is pregnant, estimated time of delivery, their MMT clinic and appointment dates/times. The log book will be maintained by the Unit Secretary as well as calling and make actual appointments. Thresholds: If a woman is admitted and we find out she is pregnant during admit; if possible will set up pre-natal with existing OB. If not - we will set one up with Women's Center at Jennersville Hospital. These calls will begin to be made within 24 hours or learning of the pregnancy.
If someone is admitted pregnant, all pre-existing pre-natal appointments will be attended. When that is not possible due to geography, the patient will be sent to Women's Center at Jennersville Hospital.
The process for prenatal is already in place, however, the timeliness is what will be audited moving forward. Weekly, the DON will be responsible for auditing the log book to assure all pregnant females have timely appointments scheduled and remain compliant with process. |
709.52(e)(1) LICENSURE Medical/dental support services
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(1) Medical/dental.
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Observations
The facility failed to document that the patients represented by client records #1 and #2 had been given assistance in obtaining prenatal care by referral to appropriate health-care providers. 28 Pa. Code Subsection 715.10(b) and (c) clearly require that the patients be given an opportunity for such care.
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Plan of Correction
A log book has been created by the DON and started as of 4/5/07. This log book includes how many weeks patient is pregnant, estimated time of delivery, their MMT clinic and appointment dates/times. The log book will be maintained by the Unit Secretary as well as calling and make actual appointments. Thresholds: If a woman is admitted and we find out she is pregnant during admit; if possible will set up pre-natal with existing OB. If not - we will set one up with Women's Center at Jennersville Hospital. These calls will begin to be made within 24 hours or learning of the pregnancy. If someone is admitted pregnant, all pre-existing pre-natal appointments will be attended. When that is not possible due to geography, the patient will be sent to Women's Center at Jennersville Hospital. The process for prenatal is already in place, however, the timeliness is what will be audited moving forward. Weekly, the DON will be responsible for auditing the log book to assure all pregnant females have timely appointments scheduled and remain compliant with process.
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709.53(a) LICENSURE Complete Client Record
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
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Observations
Client records reviewed during the unannounced inspection of February 9, 2007 were incomplete. Portions of client records were missing from each of the records reviewed. In three client records reviewed (#1, 2, and 4), components of the records which were not in place included: discharge summaries, complete records of service, case consultations and follow up documentation.
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Plan of Correction
On a weekly basis, the Clinical Director is completing random chart audits for each counselor. Part of this audit will include compliance with weekly filing requirements.
At closure of chart - medical records does complete a full chart audit. Results of this audit are given to clinical director for follow up and possible disciplinary action if needed. |
709.53(a)(4) LICENSURE Referral contact
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(4) Referral contact.
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Observations
The facility failed to ensure the patient's admission to subsequent treatment programs based on the documentation in client record # 1 and details from staff interviews. Facility staff did not finalize referral arrangements and consequently did not provide a smooth transition with the methadone treatment facility to which the patient was transported. This failure to complete the referral process and to initiate the transfer process was a violation of 28 Pa. Code Subsection 715.21(1)(i), (ii), (iii) and (iv). This patient was, in effect, terminated involuntarily from the methadone treatment program when the facility removed the patient from its physical plant and transported her to another location without the assurance that she would be admitted and dosed.
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Plan of Correction
We have conducted a process improvement committee with regards to pregnant females and MMT clinics if we should ever run into this again, however, it is our position that we did not involuntarily terminate this patient from our program.
A log book has been created by the DON and started as of 4/5/07. This log book includes how many weeks patient is pregnant, estimated time of delivery, their MMT clinic and appointment dates/times. The log book will be maintained by the Unit Secretary as well as calling and make actual appointments. Weekly, the DON will be responsible for auditing the log book to assure all pregnant females have appropriate MMT appointments scheduled prior to discharge and remain compliant with process.
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