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 February 11, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Caron Treatment Centers-Detox 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 March 19, 2009.
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Plan of Correction
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Observations
Based on the review of patient records, the facility failed to complete an initial urinalysis for four of six patient records reviewed.
The findings include:
Six patient records were reviewed on February 11, 2009. Six records required a completed urine drug screen prior to the admission and administration of the narcotic drug used for treatment. This was not done in patient records # 1, 3, 5 and 6.
Patient # 1 was admitted January 22, 2009, dosed on January 23, 2009 and the urinalysis was completed January 29, 2009.
Patient # 3 was admitted December 8, 2008, dosed on December 9, 2008 and the urinalysis was completed December 16, 2008.
Patient # 5 was admitted July 24, 2008, dosed on July 24, 2008 and the urinalysis was completed July 30, 2008.
Patient # 6 was admitted February 1, 2009, dosed on February 3, 2009 and the urinalysis was completed February 7, 2009.
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Plan of Correction
Caron Medical Department will send a UDS to an external laboratory on ALL opiate dependent admission. The Lab will pick-up daily with overnight drop and next morning by 9AM results faxed to us. The panel meets the state requirements: opiates (cut off 300), methadone, cocaine, benzo's, amphetamines and barbs .Results will state positive or negative with no quantitative or qualitative. This should all be in place by March 31st. Compliance assurance to be done by Director of Nursing. |