Observations
The facility failed to document a complete initial drug-screening urinalysis for each prospective patient in two of two patient record reviewed on January 9-10, 2018.
Patient # 4 was first dosed on October 5, 2017. There was no documentation provided of a completed initial drug-screening urinalysis.
Patient # 5 was first dosed on November 21, 2017. There was no documentation provided of a completed initial drug-screening urinalysis.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisors will hold a mandatory staff meeting before February 1, 2018 that will re-educate all staff on SPHS' policy and procedure as it pertains to individuals involved with Medicated Assisted Treatment (MAT). The Supervisors will emphasize the necessity of sending out initial drug screening urinalyses for laboratory testing and receiving confirmatory drug test results before proceeding to the provision of Suboxone. Staff will be informed that all individuals on MAT tracks must undergo random monthly urinalyses thereafter in order to continue to receive Suboxone, and said random monthly urinalyses require confirmatory drug test results from a laboratory for individuals to continue to receive Suboxone. The correction will be implemented and completed before February 1, 2018. |