INITIAL COMMENTS
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This report is a result of an on-site licensure renewal, methadone monitoring inspection, and complaint investigation conducted on February 28 - 29, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, 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. 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(iv) Outdated drugs are removed.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 administrative documentation, the facility failed document the inspection of storage areas at least quarterly.
The policy and procedure states quarterly inspections will be completed.
The inspection of medication storage area documentation was reviewed from March 2023 to December 2023. The June 2023 inspection was not signed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will review the policy and procedure manual regarding the quarterly inspections of storage areas with the nursing staff. Nursing staff will complete and submit the quarterly inspections to the facility director quarterly for sign off to ensure compliance. |