Initial Comments:
A focused fundamental survey visit was completed on September 27-28, 2023. The purpose of this visit was to evaluate compliance with the Requirements of 42 CFR, Part 483, Subpart I Regulations for Intermediate Care Facilities for Individuals with Intellectual Disabilities. The census at the time of the visit was five, and the sample consisted of three individuals.
Plan of Correction:
483.460(l)(2) STANDARD
DRUG STORAGE AND RECORDKEEPING
Name - Component - 00
The facility must keep all drugs and biologicals locked except when being prepared for administration.
Observations:
Based on observation and interview with facility staff, the facility failed to ensure that all drugs and biologicals are locked except when being prepared for administration for one of three sample Individuals observed receiving medications.
Findings included:
Observations completed on 09/27/2023 from 7:13 to 7:40 AM revealed during the medication administration process, the staff person who was administering medications walked out of the office leaving the office door and the medication closet door open where all oral and topical medications are located. During this observation period, this staff person left the medication closet door open on three ocassions, 7:13 AM, 7:22 AM, for periods of approximately 30 seconds and one minute, and at 7:35 AM while this staff went to administer Individual #1's medications in the living room. On at least one occasion, at
7:35 AM when these unlocked medications were left unattended, Individual #1 who is ambulatory, was observed to be quickly darting around living areas near the office door.
Examples of oral medications stored in the medication closet included anti-anxiety medications, e.g. lorazepam (a.k.a. Ativan ), neurologic and psychoactive medications e.g. Keppra , Risperidone, and cardiac medications e.g. Catapress.
Interview with the staff person who administered medications completed on on 09/27/23 at approximately 7:40 AM revealed this interviewee acknowledged that the medication closet door where oral and topical medications are stored remained unlocked and unattended during the times noted above.
Plan of Correction:1.The QIDP will re-train all staff on medication administration. Particular emphasis will be paid to ensuring the medication closet and all medications are locked each and every time, except during preparation and administration. This retraining will include the medication storage procedures from the Medication Administration policy. Documentation will be the Medication Administration Training form.
2.Performance Management steps have been completed for the worker on shift who was responsible for medication administration and ensuring proper procedures were followed. Documentation is the file for this worker.
3.Twice weekly the Home Manager will observe randomly selected medication trained staff administer medications. The Home Manager will document if active treatment is occurring and ensure medication trained staff are following the BARC policy and procedures for locking and storing medications. Any procedures not being followed will be documented and performance management steps will be taken. Documentation will be the MEDICATION OBSERVATION sheet.
4.Twice monthly the QIDP will observe randomly selected medication trained staff administer medications. The QIDP will document if active treatment is occurring and ensure medication trained staff are following the BARC policy and procedures for locking and storing medications. Any procedures not being followed will be documented and performance management steps will be taken. Documentation will be the MEDICATION OBSERVATION sheet.
5.Once monthly the Program Director will review all documentation associated with this plan of correction to ensure that all training and reviews are occurring as required. Any missing documentation or incorrect documentation will be immediately addressed with the associate responsible and documented. Documentation will be via the MEDICATION OBSERVATION sheet.
6.All Documentation will be kept in a Plan of Correction binder in the ICF Program Director's office.
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