INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on November 5-8, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Tadiso, Inc. 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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709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
The facility failed to file a written incident report with the Department within 3 business days following an unusual incident involving patient deaths.
The unusual incident reports were reviewed on November 6, 2019. There were 13 unusual incident reports involving patient deaths that were not reported to DDAP within 3 business days.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Tadiso was cited for not reporting patient deaths within 3 business days. However, Tadiso was using date of death as the Date of Event. Most times, Tadiso is made aware of patients' death weeks later. Tadiso will use date made aware of death as the Date of Event. The Policy Specialist is responsible for completing task and the CAO/Program Director is responsible for ensuring the completion and compliance of the task. Tadiso will be in full compliance with this standard effective 11-8-2019. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility failed to file a written incident report with the Department within 3 business days following an unusual incident requiring ambulance personnel.
The unusual incident reports were reviewed on November 6, 2019. There were 8 unusual incident reports requiring ambulance personnel that were not reported to DDAP within 3 business days.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Tadiso will file report within 3 business days following an incident requiring ambulance, and/or other emergency personnel on property. The Policy Specialist is responsible for completing task and the CAO/Program Director is responsible for ensuring the completion and compliance of the task. Tadiso will be in full compliance with this standard effective 11-8-2019. |
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
The facility failed to document that patient files were transferred to the receiving narcotic treatment program.
Patient #8 admitted on 2/6/12 and transferred on 9/25/19. There was no documentation that any information was sent to the facility where the patient transferred.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
When a patient transfers out, Tadiso will document in the patient file,that information was sent to the receiving narcotic treatment program. The Social Service Coordinators are responsible for completing the task and the Director of Social Services is responsible for ensuring the completion and compliance of the task. Tadiso will be in full compliance with this standard effective December 5, 2019. |