INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on May 24, 2022 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, St. Joseph Institute, 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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709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on a review of client charts and the Medication Management policy, the facility failed to implement their written procedures for documenting an explanation when a dose for a scheduled medication is withheld or not given.Client # 3 was admitted on September 12, 2021 and discharged on October 12, 2022. There was no documentation in the client chart regarding medication that was not given between September 25, 2022 and September 28, 2022.
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Plan of Correction
A Medication Refusal Form was implemented on 5/25/2022 by the Director of Nursing. This form will be used to document any time a resident refuses a medication. All Nursing staff was trained on the use of this form on 5/25/2022 by the Director of Nursing. The Director of Nursing will monitor compliance through monthly chart audits. |