INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on September 4 & 5, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, PA Care, LLC dba State College Medical was found not to be in compliance with the applicable chapters of 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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709.24 (a) (4) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(4) Written procedures for referral outlining cooperation with other service providers including, but not limited to, provisions for access to emergency services.
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Observations
Based on a review of client records, the facility failed to follow their written procedures for follow up contacts for clients in one out of three applicable client records reviewed. The facility ' s policy and procedures manual states that follow up contacts occur at seven days, thirty and sixty business days after discharge. Client #3 was admitted on November 16, 2015 and discharged on April 1, 2024. A follow up contact was due no later than April 10, 2024; however, it was not completed until April 11, 2024. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Follow-up policy was reviewed in 9/11/24 staff meeting by Executive Director. Tracking system will be implemented in the form of a spreadsheet which will be used to monitor when follow up calls are made for discharges to be sure that we are in compliance with our policy. Clinical Supervisor will maintain the spreadsheet and ED will monitor weekly. |
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 a review of patient records, the facility failed to document that it notified a patient's previous facility of the patient's admission including the date of initial dose in one out of two applicable records. Patient #7 was admitted on July 25, 2024 and was still active at the time of the inspection. There was no documentation that the facility notified the previous licensed narcotic treatment center documentation of the initial dose. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Process/Policy for transfer in admissions was reviewed in 9/11/24 staff meeting.
CS/ED will monitor admissions to be sure that the appropriate paperwork is completed for transfers in. Anyone who is admitted already on methadone will be treated as a transfer in, and a confirmation letter will be sent. Admission charts will be monitored within 7 days of intake to ensure compliance. |