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 May 20 - 21, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Discovery House - Nc, Inc. was found not to be compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and a plan of correction is due on June 12, 2010. .
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Plan of Correction
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Observations
Based on a review of patient records and an interview with the facility director, the facility failed to ensure that the patient was initially dosed following the completion of a drug-screen urinalysis in one of ten patient records.
The findings included:
Twenty patient records were reviewed on May 20 - 21, 2010. Ten patient records were reviewed for drug screen urinalysis results prior to a patient's initial dose. Per regulation, a narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter. The facility failed to document the completion of a drug screen urinalysis prior to dosing in patient record # 1.
Patient # 1 was admitted into treatment on February 5, 2010. Patient # 1 received a dose of 25 mg on February 5, 2010, the same date that the patient had submitted a urine specimen for a drug-screen urinalysis. The facility director was interviewed on May 20, 2010 at approximately 3:30 PM and confirmed that the patient had been dosed before the results of the urinalysis had been received.
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Plan of Correction
The Program Director will hold an inservice training to review and reinforce the requirment to aquire a "completed" drug-screening urinalysis prior to the readmission of a patient. This training will include the entire medical staff and be completed within 14 days. The Program Director will monitor each readmission process to ensure compliance. |