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 January 12, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare, Inc., was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. Deficiencies were identified during this inspection and plan of correction is due on February 7, 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 drug screen urinalysis prior to the administration of Subutex, a narcotic agent, in two of three patient records. A complete urine drug screen includes receiving the results from the CLIA and Department of Health approved laboratory.
The findings include:
Three patient records were reviewed on January 12, 2010. Three patient records were required to include documentation of a complete a drug screen urinalysis prior to the administration of Subutex, 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 drug screen urinalysis prior to the administration of Subutex, a narcotic agent, in two of the three records.
Record # 2- Patient was admitted on 11-1-09 and was discharged on 11-5-09. The urine screen was obtained on 11-2-09, and the results were received on 11-4-09. The first dose of Subutex was given on 11-2-09 at 9:00 am.
Record #3 - Patient was admitted on 12-9-09 and was discharged on 12-21-09. The urine screen was obtained on 12-10-09, and the results were received on 12-12-09. The first dose of Subutex was given on 12-10-09 at 11:30 am.
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Plan of Correction
The facility changed the urine drug screen to non-confirmatory so that we have the results back the next morning before the client has the face-to-face with the physician and order written for the Subutex. The facility also changed our admission times so that the clients are at the facility for the 4:30pm pick-up time for the Quest courier.
The facilty will continue this procedure until the CLIA level II approval at which point the facility will request an exception. |