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 patient records, the narcotic treatment program failed to transfer patient files, to include the admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, to another narcotic treatment program upon the transfer of the patient in two of two applicable patient records reviewed.
Patient #10 was admitted to the inpatient hospital residential activity on June 27, 2024 and was discharged and transferred to another narcotic treatment program on July 11, 2024. There was no documentation in the record indicating any of the required record information was transferred to the receiving narcotic treatment program at the time of the inspection.
Patient #12 was admitted to the inpatient hospital residential activity on June 7, 2024 and was discharged and transferred to another narcotic treatment program on June 18, 2024. There was no documentation in the record indicating any of the required record information was transferred to the other narcotic treatment program at the time of the inspection.
This is a repeat citation from the February 6, 2024 annual licensing renewal inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The following actions were taken to address documentation of patient care coordination:
EMR:
Enhancements have been made to our Electronic Medical Record (EMR) system to ensure comprehensive documentation of all pertinent patient information.
The case management team received additional training on how to utilize the updated EMR system features. Training took place on 8/15/24. Attendance was documented.
Audit Tool Update:
The departmental monitoring tool has been updated to reflect these requirements. The ongoing monitoring process includes:
1. Review of documentation to verify the inclusion of all required information
2. Identifying and addressing any deficiencies timely
Ongoing oversight and management will be completed by Case Management Supervisor and Clinical Director.
The Compliance Department will continue to provide monthly auditing of this measure under Quality Assurance and Performance Improvement (QAPI) program
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