INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on June 22, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Gateway Rehabilitation Center - Mount Pleasant 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(iv) Outdated drugs are removed.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
Based on a review of the medication storage area and medication reports, the facility failed to document quarterly inspections of the medication storage area.
Quarterly inspections of the medication storage area were reviewed for the October 2019 through May 2021 time period. Only one quarterly inspection was documented in October 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Nursing has scheduled quarterly inspections with our contracted pharmacy. A pharmacist will be on-site for the inspections. During inspection, they will examine medications, expiration dates and physical appearance of carts ensuring the locking mechanism is working. Expired meds will be pulled and disposed of according to Gateway Rehabilitation Center medication disposal policy. Gateway Rehabilitation Center will retain copies of the consultant pharmacy inspections for 3 years.
The Nursing Supervisor will conduct a secondary audit of medications, expiration dates, open and dated vials and physical appearance of carts ensuring the locking mechanism is working. Expired meds will be pulled and disposed of according to Gateway Rehabilitation Center medication disposal policy. Medication Audit results will be retained for 3 years.
The contracted Pharmacy staff have been educated on the Medication Control standard and Gateway Rehabilitation Center's policy on medication control on June 30, 2021. All applicable nursing staff will be trained on quarterly medication control and Gateway Rehabilitation Center's policy by July 15, 2021.
Our first quarterly medication control audit took place on June 30, 2021.
The Director of Nursing is responsible for ensuring that this procedure is being followed monthly and quarterly.
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