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 residential detoxification from opioid dependence. This inspection was conducted on October 21, 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 November 10, 2010.
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Plan of Correction
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715.17(c)(4)(i-viii) LICENSURE Medication control
(c) A narcotic treatment program shall develop and implement written policies and procedures regarding the medications used by patients which shall include, at a minimum:
(4) Method for control and accountability of drugs. A narcotic treatment program shall develop and implement written policies and procedures regarding who is authorized to remove drugs from the storage area and the method for accounting for all stored drugs. An agent or other drug prescribed or administered shall be documented on an individual medication record or sheet in a manner sufficient to maintain an accurate accounting of medication at all times and shall include:
(i) The name of the medication.
(ii) The date prescribed.
(iii) The dosage.
(iv) The frequency.
(v) The route of administration.
(vi) The date and time administered.
(vii) The name of the person administering the medication.
(viii) The take-home schedule, if applicable.
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Observations
Based on the review of patient records, the facility failed to document the date on the medication administration record in 4 of 4 patient records.
The findings include:
Four patient records were reviewed on October 21, 2010. All four patient records did not include the month on the medication administration record forms. This was confirmed with the Assistant Director of Nursing.
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Plan of Correction
The Nursing Supervisor will retrain the Nursing staff to ensure the medication administration records (MARs)are dated properly, including month of MAR and date of new orders. This will be placed on the Chart Monitors to ensure completion. This Plan Of Correction will be completed by 12/10/10. |