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 October 27, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare Inc - Transitions 2, 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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Observations
Based on review of the patient records, the facility failed to obtain a complete drug screen urinalysis prior to the administration of Suboxone/Subutex, a narcotic agent, in two of seven patient records. A complete drug screen includes receiving the results from the CLIA and Department of Health approved laboratory.
The findings include:
Seven patient records were reviewed on October 27, 2011. Seven patient records were required to include documentation of a drug screen urinalysis prior to the administration of Suboxone/Subutex, a narcotic agent. A complete drug screen includes receiving the results from the CLIA and Department of Health approved laboratory. The facility failed to obtain a complete drug screen urinalysis prior to the administration of Suboxone/Subutex, a narcotic agent in two of seven patient records.
Patient record #5 - The patient was admitted on July 30, 2011, and was discharged on August 4, 2011. The urinalysis results were not available during the record review on October 27, 2011. The initial dose of Suboxone was given on July 31, 2011 at 2:00 PM. The facility failed to document a complete drug screen urinalysis prior to the administration of Suboxone, a narcotic agent, for this patient.
Patient record #9 - The patient was admitted on August 15, 2011. The urine screen results were not available during the record review on October 27, 2011. The initial dose of Subutex was given on August 16, 2011 at 12:00 PM. The facility failed to document a complete drug screen urinalysis prior to the administration of Subutex, a narcotic agent, for this patient.
This was discussed with and confirmed by the nurse manager on October 27, 2011.
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Plan of Correction
Nursing Supervisor will continue the process of gaining exception for onsite screening. In the interim, Nursing Supervisor will review and have nursing acknowledge understanding of the current protocol and monitor protocol to ensure clients are not dosed prior to results of urine screen. |