Initial Comments:
This report is the result of an unannounced onsite Medicare Recertification Survey conducted on November 29, 2021, at Wernersville Hospital. It was determined that the facility was not in compliance with the requirements of 42 CFR, Title 42, Part 482-Conditions of Participation for Hospitals.
Plan of Correction:
482.25(b)(3) STANDARD
UNUSABLE DRUGS NOT USED
Name - Component - 00
§482.25(b)(3) - Outdated, mislabeled, or otherwise unusable drugs and
biologicals must not be available for patient use
Observations:
Based on a review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to ensure outdated medications were removed from stock.
Findings include:
Review of Policy: "... Section No. 2102- Outdated Drugs, revised 7/97. Policy Statement: All outdated drugs will be removed from stock and properly disposed. Purpose: To insure[sic] that no outdated drugs are used. Procedure: 1. Each month and during the physical inventory, the pharmacy inventory will be checked for medications that expire within 3 months or 6 months if the med is rarely used. ... If a special med was ordered for one patient and it is no longer needed, unopened packages should be returned to the wholesaler when possible. ... 3. Each month, the pharmacist, or designee will check the stock for any medications that will expire at the end of that month or within 3 months. 4. All outdated medication will be removed from stock and placed in a segregated area for return or disposal. ... "
Tour of the Pharmacy November 29, 2021 revealed on a shelf were fifty (50) tablets of Demeclocycline (medication used to treat infections) with expiration date 11/20/2021.
November 29, 2021 at approximately 2:00 PM EMP (1) confirmed the medication was expired and should have been pulled as patient no longer on it.
Plan of Correction:Review Pharmacy Policy 2102-Outdated drugs with staff and provide training such as flagging medications. Completed by 01/14/2022.
Every month the pharmacy manager will monitor the soon-to-expire drugs are being flagged properly or removed before the next inventory inspection and document the findings.
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