This report is a result of an on-site inspection conducted for the approval to use a narcotic agent, specifically buprenorphine, in the residential detoxification from opioid dependence. This inspection was conducted on September 3-4, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Marworth was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on October 7, 2008.
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Plan of Correction
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Observations
Based on the review of five patient records on September 4, 2008 four records were reviewed for the initial drug-screening urinalysis. The facility failed to obtain a complete urine drug screen prior to the administration of Suboxone, a narcotic agent in four of the four records reviewed. A complete urine drug screen includes receiving the results from the CLIA and Department of Health approved laboratory.
Findings:
Record # 1, admitted on August 21, 2008 and contained documentation of a rapid urine testing result that was completed on admission. The patient was initially administered Suboxone on August 22, 2008. The completed urine drug screen from the approved laboratory on record was completed and submitted to the facility on August 25, 2008.
Record # 2, admitted on August 29, 2008 and contained documentation of a rapid urine testing result that was completed on admission. The patient was initially administered Suboxone on August 31, 2008. The completed urine drug screen from the approved laboratory on record was completed and submitted to the facility on September 2, 2008.
Record # 3, admitted on August 26, 2008 and contained documentation of a rapid urine testing result that was completed on admission. The patient was initially administered Suboxone on August 27, 2008. The completed urine drug screen from the approved laboratory on record was completed and submitted to the facility on August 29, 2008.
Record # 4, admitted on August 12, 2008 and contained documentation of a rapid urine testing result that was completed on admission. The patient was initially administered Suboxone on August 13, 2008. The completed urine drug screen from the approved laboratory on record was completed and submitted to the facility on August 18, 2008.
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Plan of Correction
Marworth has an agreement in place with a CLIA and Department of Health approved laboratory.Marworth will wait for the results of urine drug screens from the lab before initiating Suboxone detoxification.Marworth Medical Director is working with the lab to reduce the turn around time on screens in order to maximize compliance with 715.14[a].
Responsible person:Medical Director for Marworth. |