Observations
Based on an inspection of physical evidence, the facility failed to maintain the confidentiality of patients identity in accordance with 42 CFR 2.22 and 709.28 for eight of ten clients.
During the week of 12/15/2014, a member of the surrounding community discovered multiple deteriorating, clear bags of trash on the property of another local business. These deteriorating, clear bags of trash resulted in the contents creating two piles of used methadone dispensing bottles and take-home bottles. Some of the take-home bottles displayed information that identified the patients whom were attending the program at A.R.S. of Lancaster, LP. There were approximately 100 used methadone take-home bottles between the two piles. These items were provided to the Department on 1/6/2015. A sample of 10 bottles were documented as clients # 1-10. The used take-home bottles from the documented sample included client names, the name of the facility, the address of the facility, the telephone number to the facility and the date that the methadone was dispensed for clients # 2, 3, 4, 5, 7, 8, 9 and 10.
The findings were discussed with facility staff during the inspection process.
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Plan of Correction
ARS Executive Director wrote a policy for the return of take home bottles that gave responsibility to the dispensing nurse to redact all patient confidential information. This policy went into effect on 1.14.15. All staff will be fully trained on this policy by 1.20.15. ARS has also changed from clear trash bags to black trash bags to provide another layer of privacy. Finally, all staff will be completing HIPPA/Confidentiality training this calendar year. Compliance of this new policy will be monitored by the director of nursing and executive director through random monthly observations of dosing for the next six months |