INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 21, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Highland House, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection.
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Plan of Correction
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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(iv) Outdated drugs are removed.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
The facilty failed to document quarterly inspections of the medication storage area based on a review of storage area documentation during the annual licensing inspection conducted on June 21, 2017.
Quarterly inspections of the medication storage area were only documented for April 29, 2016 and September 14, 2016.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility administrator will be maintaining and scheduling all quarterly inspections for medications. The administrator will schedule the following inspection during the time a quarterly inspection is taking place and document the quarterly inspection in the electronic daily schedule so all staff will be made aware. The life skills technician will follow this procedure should the administrator be unavailable. The documents will be maintained in the Administrator's office. |