INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and 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 November 15-17, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Dolminis was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
The facility failed to document that a verbal order was authenticated in writing within 3 business days from the time the order was given in one of two patient records reviewed on November 15-17, 2016. Seventeen patient records were reviewed on November 15-17, 2016. Two contained verbal orders. Patient record # 2 documented a verbal order received by nursing staff on July 20, 2016. The order had not been authenticated in writing by a physician as of November 16, 2016.These finding were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A verbal order was received by nursing staff on 7/20/16 and was not signed by the physician.
Nursing staff will review all verbal orders for physician signature upon completion of paperwork and return to nursing staff.
Compliance will be monitored by the DON and program director through quarterly chart reviews.
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
The facility failed to document, in writing, of a decision to involuntarily terminate the patient ' s treatment at the project and/ or the reason for termination in two of two patient records reviewed on November 15-17, 2016. Seventeen patient records were reviewed. Two records were reviewed as involuntary discharges. There was no documentation in patient record # 9 that the patient had been given written notification of the decision to involuntarily terminate the patient. There was no documentation in patient record # 10 that the patient had been given the reason for termination. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors will identify the reason for discharge in the follow-up letter sent to clients who have been involuntarily discharged from the program. Implementation will occur by 12/1/16.
Counselors will ensure that the notice of involuntary discharge is signed by the client and documented if client refuses to sign. Implementation will occur by 12/1/16.
Clinical supervisor and lead counselor will monitor involuntary discharge forms and follow-up letters during audit of discharged charts monthly.
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