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 May 25 - 26, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Summit Medical Services was found not to be compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and a plan of correction is due on June 15, 2010.
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Plan of Correction
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Observations
Based on a review of patient records, the policy and procedure manual and an interview with the facility director, the facility failed to restrict their policy and procedure regarding involuntary terminations to those areas specified in the regulation.
The findings include:
Fifteen patient records and the policy and procedure manual were reviewed on May 25 - 26, 2010. Per regulation, a narcotic treatment program shall develop policies and procedures regarding involuntary terminations. The patient records contained documentation of forms patients are requested to sign at the time of admission. One of these forms specified reasons that could lead to the termination of patients. The reasons exceeded those imposed by the regulations. The form indicated the reasons for termination included: loitering, possession of a lethal weapon, destruction of property, missed counseling sessions, providing a false urine specimen and consistent positive urinalysis. The facility's patient handbook specified a patient could be discharged for the following reasons which also exceeded those allowed by regulation: possession of lethal weapons, destruction of property and excessive loitering, providing a false urinalysis and a consistent positive urinalysis. The facility's policy and procedure manual indicated that a patient could be involuntarily terminated for destruction of property, providing a false urinalysis and a consistent positive urinalysis. These reasons exceeded those allowed by the regulation.
On May 25, 2010 the facility director was interviewed and confirmed that the information listed on the patient admission form, the policy and procedure manual and the patient handbook exceeded the reasons for involuntary termination that are permitted by the regulation.
This is a repeat citation from the inspection conducted on May 20, 2009.
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Plan of Correction
As per standard 715.21, Summit Medical Services policies and procedures, patient handbook and forms patients sign at time of admission will be changed to reflect the following reasons for involuntary termination of a patient: (1) The patient has committed or threatened to commit acts of physical violence in and around the premesis of Summit Medical Services, (2) The patient possessed a controlled substance without a prescrioption or sold or distributed a controlled substance, in and around the premesis of Summit Medical Services, (3) The patient has been absent from Summit Medical Services for 3 consecutive days or longer without cause, (4) The patient has failed to follow treatment plan objectives.
This change will be effective as of today (6/7/10) and the changes will be made by the Facility Director. |