This report is a result of an on-site inspection conducted for the approval to use a narcotic agent, specifically buprenorphine, in the residential detoxification from opioid dependence. This inspection was conducted on September 12, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cove Forge Behavioral Health System at Williamsburg, 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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Observations
Based on the review of patient records, the facility failed to document the attempt or completion of patient follow up contact in one of two patient records reviewed.
The findings include:
Four patient records were reviewed September 11, 2012. Two patient records required documentation of an attempt or completion of a follow up contact.
Patient # 3 was admitted February 8, 2012. The patient was discharged as having completed treatment on September 13, 2012. The follow up contact was required to have been attempted within seven days of the referral appointment. The follow up was not completed as of September 11, 2012.
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Plan of Correction
715.23(b)(24) LICENSURE
Patient records:
(b) Each patient file shall include the following information: (24) Follow-up information regarding the patient.
Detox only:
There shall be a complete client record on every client at Cove Forge which includes follow-up information.
The detox counselors will be responsible for filling out the follow-up form on all detox only clients and turning it into the medical secretary.
The medical secretary will be responsible for completing the follow up calls and making sure they get sent to medical records.
Detox counselors and medical secretary will be reeducated on the follow up policy and use of the form on 10-25-12.
Nursing supervisor and medical secretary will monitor detox only charts monthly for compliance on detox only or early d\c's.
Discharge from Rehab:
The Assistant Program Director will conduct 10 chart audits per month and will be review the case managers progress notes as well as the follow up documentation to ensure that all are in compliance.
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