INITIAL COMMENTS
|
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 April 1-3, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Tadiso, Inc. 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.
|
Plan of Correction
|
715.15(b) LICENSURE Medication dosage
(b) The narcotic treatment physician shall determine the proper dosage level for a patient, except as otherwise provided in this section. If the narcotic treatment physician determining the initial dose is not the narcotic treatment physician who conducted the patient examination, the narcotic treatment physician shall consult with the narcotic treatment physician who performed the examination before determining the patient 's initial dose and schedule.
|
Observations
Based on a review of patient records, the narcotic treatment program failed to document the consultation between the narcotic treatment physician determining the initial dose and the narcotic treatment physician performing the physical examination in 5 of 15 patient records.
The findings include:
Twenty eight patient records were reviewed on April 1-3, 2013. Fifteen of the patients reviewed had an initial physical within the timeframe under review. All fifteen patient records are required to include documentation of a consultation between the narcotic treatment physician determining the initial dose and the narcotic treatment physician performing the physical examination. The facility failed to document a consultation between the physician completing the intake physical and the physician ordering the initial dose in patient records # 8, 18, 19, 20 and 21.
Patient #8 was admitted on March 5, 2013. The contracted narcotic treatment physician completed the initial physical examination on March 4, 2013. The medical director determined the initial dose on March 5, 2013. There was no documentation of a consultation between the contracted narcotic treatment physician and the medical director.
Patient #18 was admitted on February 21, 2013. The contracted narcotic treatment physician completed the initial physical examination on February 20, 2013. The medical director determined the initial dose on February 21, 2013. There was no documentation of a consultation between the contracted narcotic treatment physician and the medical director.
Patient #19 was admitted on February 22, 2013. The contracted narcotic treatment physician completed the initial physical examination on February 21, 2013. The medical director determined the initial dose on February 22, 2013. There was no documentation of a consultation between the contracted narcotic treatment physician and the medical director.
Patient #20 was admitted on February 28, 2013. The contracted narcotic treatment physician completed the initial physical examination on February 27, 2013. The medical director determined the initial dose on February 28, 2013. There was no documentation of a consultation between the contracted narcotic treatment physician and the medical director.
Patient #21 was admitted on February 22, 2013. The contracted narcotic treatment physician completed the initial physical examination on February 21, 2013. The medical director determined the initial dose on February 22, 2013. There was no documentation of a consultation between the contracted narcotic treatment physician and the medical director.
An interview with the nursing supervisor was conducted on April 3, 2013 at which time the aforementioned information was confirmed.
|
Plan of Correction
If the physician providing the intake physical examination is not the physician prescribing the intial dose, a MD note will be entered into the patient chart documenting a consultation between the two physicians. This will be effective as of 4/25/2013. |
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.
|
Observations
Based on a review of patient records, the facility failed to 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 in two of three patient records.
The findings include:
Twenty eight patient records were reviewed on April 1-3, 2013. Three patients were transferred into treatment from another narcotic treatment program. All three patient records were required to include documentation that the transferring narcotic treatment program was notified regarding the patient's admission and date of initial dose. The facility failed to 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 in records # 15 and 16.
Patient #15 was transferred and admitted into treatment on January 17, 2013. There was no documentation that the facility notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient.
Patient #16 was transferred and admitted into treatment on January 25, 2013. There was no documentation that the facility notified the transferring narcotic treatment program of the admission of the patient and the date of the initial dose given to the patient.
The clinical supervisor was interviewed on April 3, 2013 at which time the aforementioned information was confirmed.
|
Plan of Correction
All documentation related to the transfer of a patient from another narcotic treatment program will be entered into the patient chart. This documentation will include the date the document was sent, the patient's date of admission and date of initial dose. The Director of Social Services will be responsible for monitoring adherence to this process. This procedure will be effective 4/25/2013. |
715.21(1)(i-iv) LICENSURE Patient termination
A narcotic treatment program shall develop and implement policies and procedures regarding involuntary terminations. Involuntary terminations shall be initiated only when all other efforts to retain the patient in the program have failed.
(1) A narcotic treatment program may involuntarily terminate a patient from the narcotic treatment program if it deems that the termination would be in the best interests of the health or safety of the patient and others, or the program finds any of the following conditions to exist:
(i) The patient has committed or threatened to commit acts of physical violence in or around the narcotic treatment program premises.
(ii) The patient possessed a controlled substance without a prescription or sold or distributed a controlled substance, in or around the narcotic treatment program premises.
(iii) The patient has been absent from the narcotic treatment program for 3 consecutive days or longer without cause.
(iv) The patient has failed to follow treatment plan objectives.
|
Observations
Based on a review of patient records, the facility failed to document approved conditions for involuntary termination in two of three patient records.
The findings include:
Twenty eight patient records were reviewed on April 1-3, 2013. Three of the patients reviewed were involuntarily terminated from treatment. All three patient records required documentation of an approved condition for involuntary termination. The facility failed to document an approved condition for involuntary termination in patient records #4 and 5.
Patient #4 was involuntarily terminated on March 18, 2013. The reason listed for involuntary termination was billing issues, which is not an approved condition.
Patient #5 was involuntarily terminated on March 18, 2013. The reason listed for involuntary termination was falsifying information, which is not an approved condition.
The chief financial officer was interviewed on April 3, 2013 at which time the aforementioned information was confirmed.
|
Plan of Correction
All involuntary terminations of patients will be reviewed by the Director of
Social Services to assure the termination was based on an approved condition for involuntary termination. No patient will be involuntarily terminated unless it has been deemed to be an approved condition. The Chief Operations Officer will monitor all terminations quarterly to assure adherence to the procedure. Effective 4/25/2013. |
715.23(b)(23) LICENSURE Patient records
(b) Each patient file shall include the following information:
(23) Discharge summary.
|
Observations
Based on a review of patient records, the facility failed to document a discharge summary within seven days of discharge in three of nine patient records.
The findings include:
Nine discharged patient records were reviewed on April 1-3, 2013. A discharge summary, which is to be completed within seven days of discharge, was required in all nine patient records. The facility did not document a discharge summary within seven days of discharge in patient records # 1, 4 and 22.
Patient #1 was admitted to treatment on January 31, 2013 and discharged on February 27, 2013. A discharge summary was due to be completed by March 6, 2013. The discharge summary was completed on March 28, 2013.
Patient #4 was admitted to treatment on June 18, 2012 and discharged on March 18, 2013. A discharge summary was due to be completed by March 25, 2013. The discharge summary was completed on April 1, 2013.
Patient #22 was admitted to treatment on February 14, 2012 and discharged on March 18, 2013. A discharge summary was due to be completed by March 25, 2013. The discharge summary was completed on March 28, 2013.
An interview with the clinical supervisor took place on April 3, 2013 at which time the aforementioned information was confirmed.
|
Plan of Correction
All documentation of patient records for discharge will be reviewed by the Director of Social Services or the Assistant Director of Social Services on a weekly basis to monitor compliance with the timeliness of the completion of the discharge summary. This review will begin effective April 25, 2013. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
|
Observations
Based on a review of patient records, the facility failed to document the signature of the medical director on the annual evaluation in three of the five patient records.
The findings include:
Twenty eight patient records were reviewed on April 1-3, 2013. Five of the twenty eight patient records reviewed were required to include documentation of an annual evaluation including the medical director's signature. The facility failed to document the medical director's signature on the annual evaluation in patient records #24, 26 and 28.
Patient record # 24 was admitted to treatment on March 8, 2012. The annual evaluation was completed on March 8, 2013. The annual evaluation did not include the medical director's signature.
Patient record # 26 was admitted to treatment on February 1, 2012. The annual evaluation was completed on February 22, 2013. The annual evaluation did not include the medical director's signature.
Patient record # 28 was admitted to treatment on February 7, 2012. The annual evaluation was completed on February 26, 2013. The annual evaluation did not include the medical director's signature.
An interview with the nursing supervisor, clinical supervisor and project director took place on April 3, 2013 at which time the aforementioned information was confirmed
|
Plan of Correction
The Medical Director will sign off on all annual evaluations for patients. The Chief Operations Officer will monitor compliance with this procedure. Effective 4/25/2013. |