INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on May 15, 2024, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Gatehouse Mountville 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) 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:
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Observations
Based on a review of client medical records and the Medication Control policy, the facility failed to implement its policy and procedures regarding all medications used by clients.
The Medication Control policy indicates documentation that medication was or was not taken by the client will be documented in the Medication Administration Record. Staff will review medications sheets to ensure proper documentation has been recorded, to include medications that have been refused by the client.
Client #2 was admitted on February 6, 2024, and discharged on April 24, 2024. The client was prescribed a medication and the prescription stated that two tablet were to be taken at bedtime. The medication administration record was found to be blank on March 2, 24, 27, and 30, 2024. Additionally, client #2 was prescribed a medication and the prescription stated that one tablet was to be taken at bedtime. The medication administration record was found to be blank on March 24, 27, and 30, 2024.
Client #3 was admitted on March 27, 2024, and discharged on May 9, 2024 . The client was prescribed a medication and the prescription stated that one capsule was to be taken every morning. The medication administration record was found to be blank on April 4, 5, 21, 23, and 25, 2024. Additionally, client #3 was prescribed a medication and the prescription stated that one film was to be taken twice a day. The medication administration record reflected the medication was given once on April 23, 25, 27, 29, and 30, 2024 with no documentation in the record as to why the second dose was not given. The medication administration record was found to be blank on April 28, 2024.
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Plan of Correction
In an effort to address citation number 709.32 (c), the following will be implemented:
Beginning on 5/29/2024, the Residential Program Supervisor will ensure that the "Medication Control" policy is adhered to by all staff. The Residential Program Supervisor will specifically focus on training all the staff that observe the clients self-administration of medications to indicate a reason on the MAR that a client has not taken a prescribed medication. In addition, the Residential Program Supervisor will review the MARS bi-weekly to ensure that there are no blank spaces.
The Program Director will meet monthly with the Residential Program Supervisor to monitor the consistency of the procedure listed above. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of client medical records, the facility failed to provide documentation of medication being provided as prescribed by a physician.
Client # 1 was admitted on January 5, 2024 and discharged on April 29, 2024 . The client was prescribed a medication and the prescription stated that it was to be taken once daily. The medication administration records showed that the medication was not given on January 16,2024 due to failure to fill the script. Additionally, client #1 was prescribed a medication and the prescription stated that one film daily in the morning. The medication administration records showed that the medication was not given on March 10, 2024, due to failure to fill the script.
Client #2 was admitted on February 6, 2024, and discharged on April 24, 2024 . The client was prescribed a medication and the prescription stated that two tablet were to be taken at bedtime. The medication administration records showed that the medication was not given on March 2, 24, 27, and 30, 2024. Additionally, client #2 was prescribed a medication and the prescription stated that one tablet was to be taken at bedtime. The medication administration records showed that the medication was not given on March 24, 27, and 30, 2024.
Client #3 was admitted on March 27, 2024, and discharged on May 9, 2024. The client was prescribed a medication and the prescription stated that one capsule was to be taken every morning. The medication administration records showed that the medication was not given on April 4, 5, 21, 23, and 25, 2024. Additionally, client #3 was prescribed a medication and the prescription stated that one film was to be taken twice a day. The medication administration records showed that the medication was only given once on April 23, 25, 27, 29, and 30, 2024. The medication administration records indicate that the medication was not given on April 28, 2024.
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Plan of Correction
In an effort to address citation number 709.32 (4) (i) (ii), the following will be implemented:
Beginning on 5/29/2024, the Residential Program Supervisor and Program Director will ensure that a monthly inspection is completed and all discontinued and expired medication is discarded and documented.
The Residential Program Supervisor and Case Manager will ensure that the MARS is up to date and includes the name of the medication, the prescribed dosage, and time to be administered. The Residential Program Supervisor will complete a bi-weekly audit of the MARS to ensure that the staff are recording their initials on the correct date and time listed on the MARS each time they observe the clients self-administering their medication.
The Executive Director will monitor this procedure with the Program Director during monthly supervision. |