INITIAL COMMENTS
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This report is a result of an onsite licensure renewal and methadone monitoring inspection. The inspection was conducted on October 20-21, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite inspection, Center for Behavioral Health - HA, Inc. 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 the 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
The facility failed to document that it notified the referring facility of the admission and initial dosing of the patient in 2 of 4 patient records.
Twelve patient records were reviewed on October 20 & 21, 2016. Four of the patients reviewed transferred to the facility from another narcotic treatment program.
Patient # 6 was admitted on April 7, 2016 and patient # 10 was admitted on December 21, 2015. Both patients were referred by another narcotic treatment program and there was no documentation of the transferring facility being notified of the admission and initial dosing of the patients.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinic Director met with Program Manager on 10/24/16 to discuss the procedure for completing Transfer Acknowledgments on all incoming transfers. Program Manager completes intakes for all admissions. Program Manager will ensure that Transfer Acknowledgment forms are completed for every patient who transfers to our facility from another MMT. The Transfer Acknowledgments will be completed on the day of the transfer admission. The Transfer Acknowledgment will then be faxed to the transferring clinic. Program Manager will keep a copy of the fax transmittal sheet that shows the Transfer Acknowledgement was faxed successfully. Both the Transfer Acknowledgment Form and fax transmittal sheet will be scanned into the "Stored Images' section of the patient's EHR. |