INITIAL COMMENTS
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This report is a result of an on-site inspection conducted for the approval to use a narcotic agent, specifically Methadone, in the treatment of narcotic addiction. This inspection was conducted on June 23 -25, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Tadiso Inc. was found not to be in compliance with the applicable chapters of 4 PA Code and 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on July 22, 2009.
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Plan of Correction
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on a review of the administrative documentation, the facility failed to document the physician services at least 1 hour per week onsite for every ten patients for one of four weeks reviewed.
The findings include:
Four weeks of physician services, in the form of time sheets, were reviewed on June 24, 2009. The weeks of March 1, 2009, March 23, 2009, April 20, 2009, and May 4, 2009 were reviewed. The facility did not document physician services at least 1 hour per week onsite for every ten patients in one of the four weeks reviewed. The week of May 4, 2009 required 61.5 hours of physician services, but documentation identified that only 57.9 hours were provided.
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Plan of Correction
Tadiso Inc. is scheduled for 67.5 hours of physcian time per week which meets the maximun requirement of serivce to the licensed capacity of 665 clients in chemotherapy(655 opmm and 10 ph). During a period where a scheduled physician is absent,back up coverage will be instituted through contractual agreement with another qualifed licensed medical personnel. This will be completed by the program sponsor by Octoer 5, 2009. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of the patient records, the facility failed to document the initial urine drug screen results were obtained by the facility prior to the patients initial medication dose in sixteen of sixteen records.
The findings include:
Twenty-two patient records were reviewed on June 23, 24, and 25, 2009. Documentation of the initial urine drug screen results was required to be obtained by the facility prior to the patient's initial medication dose in sixteen patient records. The facility did not receive the initial urine drug screen results prior to the patient's initial medication dose in records # 1, 2, 5, 6, 7, 8, 9, 11, 14, 15, 16, 17, 18, 19, 20, and 22.
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Plan of Correction
Tadiso Inc. has ceased same day admission process effective June 29, 2009. The intake process has changed and applicants will be contacted to return to the facility after urine results have been received by the facility. This process will be under the supervision of the Social Service Director. Time frame is immediately. |
715.23(b)(6) LICENSURE Patient records
(b) Each patient file shall include the following information:
(6) Results of laboratory tests or other special examinations given by the narcotic treatment program.
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Observations
Based on a review of the patient records, the facility failed to document the results of laboratory tests in seven of eighteen records.
The findings include:
Twenty-two patient records were reviewed on June 23, 24, and 25, 2009. Documentation of the of laboratory results for serology tests was required to be obtained by the facility in eighteen patient records. The facility did not receive the laboratory results in seven records # 1, 3, 7, 11, 14, 16, 18.
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Plan of Correction
Tadiso Inc.attempts blood draws on all applicants. In those instances where a blood sample can not be obtained after documentation of number of attempts, the client will be asked to sign a consent form for release of medical records that may contain results of serology tests within the past year from another facility or physician. The process is under the direction of the Medical Director and the time frame for this process is August 1, 2009. |