The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

COMPASS BEHAVIORAL CENTER OF LAFAYETTE 312 YOUNGSVILLE HIGHWAY LAFAYETTE, LA Jan. 15, 2013
VIOLATION: CONFIDENTIALITY OF MEDICAL RECORDS Tag No: A0441
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation and interview the hospital failed to ensure that unauthorized individuals could not gain access to patient medical records. Findings:

Observation of the hospital's off-site campus on 1/14/13 at approximately 11:30 a.m. revealed the hospital building was unlocked and there was a person observed in the receptionist front office. Interview at that time revealed the person (S3) was an employee of the hospital's corporation, but was not an employee of the off-site campus. S3 stated she was the Residential Manager of another facility (Facility A).

Further interview with S3, Residential Manager of Facility A on 1/14/13 at approximately 11:35 a.m. revealed the hospital building was being used by Facility A for office space.

Observation during a tour of the hospital on [DATE] at approximately 12:50 p.m revealed S3 had keys to access a file room which contained medical records for the hospital. There were approximately 276 medical records stored in the room. Interview at that time with S3 confirmed the keys to the file room were accessible to other employees who did not work for the hospital.
VIOLATION: PHARMACY ADMINISTRATION Tag No: A0491
Based on observation and interview the hospital failed to ensure that:

1) employees provide pharmaceutical services within their scope of license and education as evidenced by having unlicensed staff administer a medication room for patients other than inpatients of the hospital.

2) scheduled drugs were properly stored and that control was maintained at all times by appropriate qualified staff as evidenced by 49 Clonazepam 0.5 milligram (mg) tablets stored in a room without facility control and 144 Fioricet tablets stored in a locker that was accessible by unlicensed personnel with no controls in place. Findings:

1) Observation on 1/14/13 at approximately 11:50 a.m. revealed a room that contained lockers with patient's names noted on the lockers. Interview at that time with S3, Regional Manager of another facility (Facility A), revealed the lockers contained medications which belonged to the patients at the facility where she was employed. S3 further stated that patients were responsible for their own medications. S3 stated the Mental Health Technicians (MHTs), who were also employees of a separate agency, assisted the patients with the medications.

Observation on 1/14/13 at approximately 1:25 p.m. revealed a room that contained 2 boxes measuring 18" (length) x 12"(width) x 10"(height) inches. Each box was observed to be filled with blister packs and/or bottles of medications. Various names were observed to be noted on the medications.

Interview with S3, Regional Manager of facility A during the above observation revealed the boxes contained medications that belonged to patients who had been discharged from facility A. S3 confirmed that the keys used to open the office where the medications were kept, were the same keys available to the other staff members who were employed by another agency.

2) In an observation made on 01/14/13 at 1:37 p.m. with S2RN, Corporate Compliance, there was noted to be 2 blister packs of Clonazepam 0.5 mg tablets and a single tablet with exact markings and color in a plastic bag located in an office of Compass Behavioral offsite. One blister pack contained 26 tablets and the other contained 22 tablets. S2RN, Corporate Compliance verified the single tablet appeared to be the same as the tablets in the blister packs. S2RN confirmed there were 49 tablets of a Schedule IV medication not under control of qualified personnel.

Review of a document titled "Registrants Inventory of Drugs Surrendered", presented to surveyor's on 01/15/13 at 10:00 a.m. by S2RN, Corporate Compliance, revealed the following: "The following schedule is an inventory of controlled substances which is hereby surrendered to you for proper disposition. From: Compass Behavioral Center 216 Robin Lane Opelousas, LA ...Registrant's DEA (Drug Enforcement Agency) Number - FM 50...Name of Drug or Preparation. 1. Clonazepam .5 (no leading 0) mg tab. Number of containers - 1. Contents - 48. Controlled Substance Content (each unit) .5 mg. Disposition. Flush." The document is signed by S2RN, Corporate Compliance and the consultant pharmacist dated 01/14/13. There is no documentation of the 49th tablet being destroyed.

Review of a document titled "Medication Destruction Report", presented to surveyor's on 01/15/13 at 10:00 a.m. by S2RN, Corporate Compliance, revealed the following: "The following medications were documented then rendered unusable. All listed medications were destroyed offsite by the consultant pharmacist and a witness." The document is signed by the consultant pharmacist and S2RN, Corporate Compliance. Further review of the document revealed: "(the name of the former resident of the adjacent apartment building - Facility A), Drug: clonazepam .5 (mg), RX (prescription) number 34, quantity 22, date 01/14/13 and Drug: clonazepam .5 (mg), RX number 34, quantity 26, date 01/14/13." There is no documentation of the 49th tablet being destroyed.

In an observation made on 01/14/13 at 4:00 p.m. with S2RN, Corporate Compliance the medication lockers located inside of Compass Behavioral were opened by unlicensed personnel via a pass key that opened all lockers of the tennant's of the adjacent apartments (Facility A). Review of the contents of one locker revealed 144 Fioricet tablets.

Review of a document titled (name of current tennant of adjacent apartment complex - Facility A) revealed: "I, (name of current tennant of adjacent apartment complex - Facility A), have reviewed all the medications in my locker at 8:45 p.m. on January 14, 2013. I attest that I have received all my medications and have stored them in my own personal locker. I understand that I will maintain full responsibility for my medications and that I am the only person with access to them." The document is signed by the tennant and a witness. Handwritten on the document is "24 Fioricet and 120 Fioricet in unopened bottle received by (tennant name) on 01/14/13 at 5:20 p.m." The handwritten portion is signed by S2RN, Corporate Compliance and the tennant.

Review of a hospital policy titled "PHARM-004: Loss and Abuse of Controlled Substances", Effective: July 10, 2012, no date of last revision, presented as current hospital policy, revealed in part: "Policy. In the event of loss or abuse of controlled substances, the following policy and procedure will be followed: Procedure. 1. In the event that narcotic count is off, or any evidence of tampering, missing, or abuse of narcotics is found, the Administer shall be notified immediately. 2. Pharmacist, LA Board of Pharmacy and the DEA will be notified and documentation of any evidence shall be done by a licensed nurse and verified by the pharmacist..."