709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of the facility's medication logs and controlled substance count sheets, staff interviews, and observation of the medication room, the facility failed to follow their procedures related to the disposal of medications for clients that are no longer at the facility or prescribe a different medication.The facility was transferring medications from discharged clients and clients that the medication was discontinued for to the facility's stock to administer to other clients.The facility's controlled substance count sheet had pages of medications that were previous client's medication that were marked "transferred to stock" with staff signatures and dates. The nursing staff including the Director of Nursing and the Facility Director confirmed that the medication had been transferred to stock to administer to other clients.These findings were discussed with the facility staff during the complaint investigation.
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Plan of Correction
When leadership was made aware of the above violations of policy and procedure, the practice was immediately stopped. Extensive training was conducted by the National Director of Nursing for all medical personnel at Wilkes Barre Treatment. The training reinforced our policies and procedures regarding medication storage, administration, and destruction of all discharged and discontinued medication. Training will continue on an annual basis regarding medication storage, administration, and destruction of all discharged and discontinued medication. The compliance department has created an internal medication storage checklist for the Compliance Support Specialist at Wilkes Barre Treatment to conduct monthly inspections in addition to the external pharmacy inspection that occurs quarterly. The facility is now contracted with wholesale pharmacy distributers Besse Medical and McKesson, in addition to the local pharmacy, to ensure that no supply-chain disruptions occur with medication ordered to the facility. |