INITIAL COMMENTS
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This report is a result of a complaint investigation conducted by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings, Northeast Treatment Centers - NET Steps OTP 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 and a plan of correction is due July 22, 2008. .
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Plan of Correction
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715.20 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.
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Observations
Based on a review of the facility policy and procedure manual on April 3, 2008, the facility failed to provide for a written policy that stated within 7 days of a patient's request to transfer to another narcotic treatment program the transfer would be initiated.
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Plan of Correction
RESUBMISSION
NetSteps policy on patient transfers(715.20) reads as follows: "An NTP project shall transfer any client to another NTP project for continued maintenance, detoxification, or another treatment activity within 7 days of the request"
Time Line: completed 5/1/08
Responsible: Facility Director |
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 a review of 23 patient records on April 3, 2008, only one of those patient records involved a patient's request to transfer to another Narcotic Treatment Facility. The facility failed to send the required patient files to another narcotic treatment program (NTP) within seven days of the patient's request for a transfer. The patient represented by patient record #0729 requested a transfer to another NTP as early as December 11, 2007, but the facility did not send any of the required information to the other NTP until January 30, 2008.
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Plan of Correction
RESUBMISSION
The procedure for initiating transfers to another NTP within 7 days was revised to ensure the process meets (715.20(1).
A "Request to Transfer" form was created that tracks the consumer's initial request from the counselor to the supervisor for approval, to medical records where the transfer packet is sent out. Signatures and dates are presentr the ensure the 7 days criteria ia met. The response of the receiving NTP is also indicated and documented.
Time Line: completed 5/1/08
Monitoring: PI/QA Director and Medical Records staff
Responsible: PI/QA Director and Facility Director |