Observations
Based on a review of patient records, the facility failed to ensure a random urinalysis was completed for each patient at least monthly in one of eight applicable records.
Patient #2 was admitted to the outpatient level of care on January 18, 2024 and was active at the time of review. There was no documented urinalysis for patient #2 for the month of May 2024.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Due to several issues around UA scheduling/missed UAs this facility has adapted several strategies to prevent missed UAs starting in May of 2023 which we have revised on an ongoing basis, including in June after this UA was missed:
-A physical checklist is maintained by all staff as they complete UAs. This is checked by the nurses weekly.
-Status/results of all UAs are checked by either the Nurses or by the Lead Counselor (as of April 4, 2024) weekly to verify that all completed results have been uploaded to the EHR. Any that are missing are downloaded from the lab site and added to the EHR manually.
-Nurses verify all UAs scheduled for each day and immediately manually reschedule any that run for Pts that are not scheduled to dose in clinic. Nurses then verify that the THB schedule is entered correctly in the EHR system.
-Nurses will verify that any UAs missed due to circumstances outside facility control (hospitalization, incarceration, AWOL when UA is scheduled at end-of-month) are manually documented in the "Drug Screen Results" section of the EHR.
All issues, concerns, progress is reported to the Executive Director as needed, but at minimum weekly.
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