INITIAL COMMENTS
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This report is a result of an off-site complaint investigation conducted October 18, 2024, by staff from the Bureau of Program Licensure. Based on the findings of the off-site complaint investigation, RHJ Medical Center, Inc./Vandergrift, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
The facility failed to file a written unusual incident report with the Department within 48 hours following an incident with potential for negative community reaction or community concern as evidenced by:
On October 18, 2024, the DEA emailed the DDAP regarding their visit to the facility on August 27, 2024 in which there were underages in the methadone inventory. The facility reported that the methadone pumps were not calibrated weekly as required. During that time clients received higher doses of methadone than they were prescribed. The facility did not report this incident to the Department as required.
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Plan of Correction
An unusual incident report was filed with the department 10/21/24. The pumps were calibrated, and the nurses were trained in the calibration of the new pumps and the documentation required for the calibration. The facility director will validate pump calibration monthly.
Unusual Incident reports will be filed within 48 hours when required. Leadership reviewed the requirements for the unusual incident requirements and will ensure that they are completed, when necessary, within 48 hours in order to maintain compliance. |