This report is a result of an on-site inspection conducted for the approval to use a narcotic agent, specifically buprenorphine, in the treatment of narcotic addiction. This inspection was conducted on April 13, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Caron Treatment Centers - Detox Unit was found not to be in compliance with the applicable chapters of 4 PA Code and 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection and a plan of correction is due on May 9, 2010.
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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 urine drug screen urinalysis prior to the administration of Subutex, a narcotic agent, in three of five patient records. A complete urine drug screen includes receiving the results from the CLIA and Department of Health approved laboratory.
The findings include:
Five patient records were reviewed on April 13, 2010. Five patient records were required to have a complete urine drug screen urinalysis prior to the administration of Subutex, a narcotic agent. The facility failed to obtain a complete urine drug screen urinalysis prior to the administration of Subutex, a narcotic agent in three of the five patient records.
Record #1 - Patient was admitted on 3-6-10. The first dose of Subutex was given on 3-7-10 at 11:56 AM.
The urine drug screen result was received by the facility 3-9-10.
Record #2 - Patient was admitted on 3-15-10. The first dose of Subutex was given on 3-17-10 at 06:07 AM.
The urine drug screen result was received by the facility 3-19-10.
Record #3 - Patient was admitted on 7-16-09. The first dose of Subutex was given on 7-17-09 at 05:03 PM.
The urine drug screen result was received by the facility 7-18-09.
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Plan of Correction
We have arranged with a local hospital laboratory to provide a quick turnaround time for initial drug screening urinalysis results for opioid dependent admissions to meet the intent of the standard. Compliance monitoring to be conducted by the Director of Nurses on an ongoing basis for quality control purposes.
Target Date 5/6/10
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