This report is a result of an on-site inspection conducted for the approval to use a narcotic agent, specifically methadone, in the treatment of narcotic addiction. This inspection was conducted on May 6-7, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHJ Medical Center, Inc. was found not to be in compliance with the applicable chapters of 4 PA Code and 28 PA Code which pertain to the facility.
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Plan of Correction
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Observations
Based on dosing observation and an interview with the nurses, the facility failed to physically secure and maintain the confidentiality of all patient records in accordance with 42 CFR Part 2, Subpart B, 2.22 (relating to notice to patients of Federal confidentiality requirements) and 28 Pa. Code 709.28 (relating to confidentiality).
The findings include:
During the observation of the methadone dispensing on May 7, 2014 between 10:45 AM and 11:15 AM, patients were observed showing their take home bottles to the nurses and then placing the bottles in the trash, with no removal of their name. The trash in this can is placed in with the general trash; which could be accessed by the public. This practice did not ensure that the patient's confidentiality was physically secure and maintained, as required by Federal and State regulations.
The dosing nurses were interviewed on May 7, 2014, after the completion of methadone dispensing. The dosing nurses reported that there is a sign and a black marker provided so that the patients have the option of crossing their names off the take home bottles. If the patients do not want to cross their names off the bottle; the bottles are still thrown into the general trash with the name visible. The dosing nurses confirmed they were unaware that all patient names must be removed from the bottles before placing into the general trash.
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Plan of Correction
The Project director is ultimately responsible to ensure compliance with this regulation. In order to obtain and maintain compliance the project director will hold a meeting with nursing staff to discuss the updated facility protocol that all clients will be instructed to black out the labels on all of their take home bottles prior to placing them into the trash. If clients fail to black out their name, the nursing staff will request that the take home bottles be given to them so that they may black out all identifying information on take-home bottles prior to their placement into the general trash. To ensure ongoing compliance the leadership staff will randomly observe dosing and report to the project director any failure to follow this protocol. |