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 October 8-10, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Addiction Medicine And Health Advocate 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.
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Plan of Correction
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715.11 LICENSURE Confidentiality of patient records
A narcotic treatment program shall physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR 2.22 (relating to notice to patients of Federal confidentiality requirements) and § 709.28 (relating to confidentiality).
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Observations
Based on a review of patient records, the facility failed to list the specific patient information to be disclosed on the consent to release information forms in five of nine patient records reviewed.
The findings include:
Seventeen patient records were reviewed from October 8-10, 2013. Nine patient records were specifically reviewed for consent to release patient information forms. The facility failed to list the specific patient information to be disclosed in patient records # 3, 7, 8, 16 and 17.
Patient # 3 signed four different consent to release patient information forms on September 13, 2013 that failed to document the specific patient information to be disclosed.
Patient # 7 signed a consent to release patient information form to initiate and complete a transfer to another narcotic treatment facility. The consent to release patient information form restricted the release of patient information to the limitations outlined at 4 PA Code 255.5 (b). The patient information required to initiate and complete the transfer of the patient to another narcotic treatment provider exceeded the limitations outlined at 4 PA Code 255.5 (b). The consent to release information form failed to include the specific information that would be released.
Patient # 8 signed a consent to release patient information form to initiate and complete a transfer to another narcotic treatment facility. The consent to release patient information form restricted the release of patient information to the limitations outlined at 4 PA Code 255.5 (b). The patient information required to initiate and complete the transfer of the patient to another narcotic treatment provider exceeded the limitations outlined at 4 PA Code 255.5 (b). The consent to release information form failed to include the specific information that would be released.
Patient record # 16 contained a consent to release patient information form that had no specific information documented and that was not signed by the client.. The consent form was related to the release of patient information to the referring facility, notifying the facility that the patient had been accepted and given the first dose.
Patient record # 17 contained a consent to release patient information form that had no specific information documented and that was not signed by the client.. The consent form was related to the release of patient information to the referring facility, notifying the facility that the patient had been accepted and given the first dose.
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Plan of Correction
The clinical coordinator will conduct supervision with the intake coordinator and educate him on the proper completion of the Consent to Release Information form. Speicically, he will be instructed on the importance of listing the specific information to be disclosed to the entities listed on the release form and the importance of making sure that the patient has signed the release form and dated it. The intake coordinator will also be educated on the need to use a release form that does not restrict the information disclosed to only that outlined in 4 PA 255.5, but rather allows for the release of all information necessary to complete the objective at hand. The clinical coordinator will be responsible for assuring that the proper, specific information to be disclosed is clearly listed on the Consent to Release Information form. |
715.20(3) 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.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document what materials were sent to the receiving narcotic treatment program in two of two patient records reviewed.
The findings include:
Seventeen patient records were reviewed from October 8-10, 2013. Two patient records required documentation of what materials were sent to the receiving narcotic treatment program. The facility failed to document what materials were sent to the receiving program in patient records # 7 and 8.
Patient # 7 was admitted on March 24, 2011 and was transferred to another narcotic treatment facility on November 24, 2012. There was no documentation in the patient record of what materials were sent to the receiving narcotic treatment facility at the time of the inspection.
Patient # 8 was admitted on July 19, 2012 and was transferred to another narcotic treatment facility on November 29, 2012. There was no documentation in the patient record of what materials were sent to the receiving narcotic treatment facility at the time of the inspection.
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Plan of Correction
The clinical coordinator will conduct supervision with the intake coordinator on the importance of listing all of the specific transfer documentation being sent when attempting to affect a patient transfer to another facility. The clinical coordinator will be responsible for ensuring that the proper and complete documentation is listed and then forwarded to the accepting facility when a transfer is being attempted. |
715.20(4) 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.
(4) The receiving narcotic treatment program shall document in writing that it notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient by the receiving narcotic treatment program.
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Observations
Based on the review of patient records, the facility failed to document in writing that it notified the referring facility of the admission and initial dosing of the patient in two of four patient records reviewed.
The findings include:
Seventeen patient records were reviewed October 8-10, 2013. Four patient records were reviewed for documentation of notification to the transferring facility of the admission and initial dosing of the referred patient. The facility failed to the document written notification in patient records # 15 and 16.
Patient # 15 was admitted from another narcotic treatment facility on June 10, 2013. There was no written notice of the admission and initial dosing of the patient in the patient record at the time of the inspection.
Patient # 16 was admitted from another narcotic treatment facility on September 26, 2013. There was no written notice of the admission and initial dosing of the patient in the patient record at the time of the inspection.
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Plan of Correction
The clinical coordinator will educate the intake coordinator of the importance of providing timely notification to the referring facility of the admission and initial dosing of the patient whenever a patient transfer has been completed. The clinical coordinator will be responsible for assuring that all necessary notification is sent to the referring facility in a timely fashion. |