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 the review of patient records, the facilty failed to transfer the required information from patient files in two of two patient records.
The findings include:
Ten patient records were reviewed on October 13 - 14, 2015. Two patient records required the facility to transfer specific patient information to the receiving narcotic treatment program as part of the transfer process. Required information includes: 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. Patient records # 5 and # 10 did not include documentation the information was sent.
Patient # 5 was admitted to treatment on May 29, 2015 and discharged as a transfer to another narcotic treatment facility on October 8, 2015. There was no documentation the required information was transferred to the receiving facility.
Patient # 10 was admitted to treatment on March 24, 2015 and discharged as a transfer to another narcotic treatment facility on May 22, 2015. There was no documentation the required information was transferred to the receiving facility.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Counselors will be required to transfer necessary paperwork for all patients transferring to another facility within 7 days of transfer. Program Director created a "Master Fax Cover Sheet" that can be used for faxing all patient transfer information. This cover sheet contains a list of the various documents that are to be included in the transfer fax. Counselors will check off any included items, and hand write in any additional information faxed on this cover sheet. Once the fax is successfully transmitted, the counselors will keep the "Successful Transmittal" sheet for it to be scanned into the pt's "Stored Images" section of the electronic health record (EHR). Administrative assistant will ensure that this sheet is scanned into the approrpiate EHR. During the Discharge Audit process, Clinical Supervisor will make sure that any transferred patients have had the appropriate transfer paperwork faxed, and proof of fax scanned into the pt's EHR. |