Observations
The facility failed to ensure that each female patient is fully informed of the possible risk to her or her unborn child from continued use of illicit drugs and from use of, or withdrawal from narcotic drug administered or dispensed by the program in comprehensive maintenance or detoxification treatment in one of three client records reviewed on September 21, 2017. Client record # 5 was missing documentation that the female was informed of the risks. These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The site lead therapist (NL) will conduct compliancy audits to ensure that all female patients sign the "Risks of Suboxone", "Vivitrol Warnings" and "MAT Treatment Contract" upon admission if receiving Medication Assisted Treatment.
The site lead therapist will be responsible for auditing medical records will ensure that documentation is provided in the progress notes that the above forms were signed and reviewed with the patient upon intake, or at a time when a patient status is changed from "drug free" to "medication assisted therapy".
Medical records will be audited by the lead therapist at a minimum of two times per month.
Staff will undergo a formal training pertaining to medical record documentation on October 11, 2017 by Facility Director, Clinical Supervisor and Lead Therapist, to ensure that documents are completed in a timely manner, are not omitted
from the medical record, and that all pertinent fields in the form are completed, including information, client and therapist signatures, and dates of documentation completed.
|