INITIAL COMMENTS
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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 March 15, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, UHS Recovery Foundation, Inc. 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 April 4, 2010.
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Plan of Correction
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715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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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 Suboxone, a narcotic agent in five of six patient records. A complete urine drug screen includes receiving the results from the CLIA and Department of Health approved laboratory.
The findings include:
Six patient records were reviewed on March 15, 2010. Six patient records were required to complete a urine drug screen urinalysis prior to the administration of Suboxone, a narcotic agent. A complete urine drug screen includes receiving the results from the CLIA and Department of Health approved laboratory. The facility failed to obtain a complete urine drug screen urinalysis prior to the administration of Suboxone, a narcotic agent in five of the six patient records.
Record #1 - patient was admitted and dosed on March 11, 2010. The results from the CLIA and Department of Health approved laboratory were returned March 12, 2010.
Record #3 - patient was admitted and dosed on March 8, 2010. The results from the CLIA and Department of Health approved laboratory were returned March 9, 2010.
Record #4 - patient was admitted on December 16, 2009 and dosed on December 17, 2009 at 12:20 PM. The results from the CLIA and Department of Health approved laboratory were returned December 17, 2009 at 2:57 PM.
Record #5 - patient was admitted and dosed on December 4, 2009. The results from the CLIA and Department of Health approved laboratory were returned December 5, 2009.
Record #6 - patient was admitted December 9, 2009 and dosed on December 11, 2009 without results from the CLIA and Department of Health approved laboratory.
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Plan of Correction
715.14(a):
Arrangements have been made with
our CLIA certified laboratory for
daily specimen pick-ups so that we
may meet this regulation. Medical
director included this in his
3/25/2010 review with medical and
nursing staff. Daily medical record
review by night charge nurse will
occur to monitor compliance.
Results reported
monthly to Performance
Improvement Committee.
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715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on the review of patient records, the facility failed to document the attempt or completion of patient follow up contact in three of three patient records reviewed. .
The findings include:
Six patient records were reviewed March 15, 2010. Three patient records were reviewed for follow-up documentation.
Patient records # 4, 5 and 6 did not have documentation of patient follow up attempt or contact.
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Plan of Correction
715.23(b)(23): Director of Nursing
held staff training on 3/28/10 and 3/29/10 to
review policy and procedure
regarding discharge summary
documentation and patient
follow-up documentation. Monthly
random chart audits will be
performed by DON to monitor for
compliance. Results reported
monthly to Performance
Improvement Committee.
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