Observations
Based on an interview with the facility director, the facility failed to have persons authorized by law administer or dispense a controlled substance, specifically methadone.
The findings include:
A complaint investigation was conducted on August 29, 2011. The facility director was interviewed and confirmed that she had, on a few occasions, assisted the nursing staff in preparing doses for the patients by placing the medication in a cup and then handing the cup to the nurse to dispense to the patient.
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Plan of Correction
As discussed with the inspector, there were very few occasions that the director had assisted the medical staff in this manner and that it only occurred when there was an unexpected medical staff shortage that caused a longer wait time for the clients. Medication was never given directly to a client and any assistance given by the director was monitored and checked by a licensed medical staff member. Director will not assist the medical staff in this manner again.
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