Observations
Based on the review of medication administration records, the facility failed to document the administration, or the reason a medication was not administered as prescribed in four of seven records reviewed.
Client #3 was admitted May 9, 2024 and discharged July 2, 2024. A medication was prescribed to be given four times a day. The MAR was left blank for the following dates and times:
-July 1, 2024 at 12 pm
-June 28, 2024 at 12 pm
-June 24, 2024 at 12 pm
-June 23, 2024 at 4:30 pm
-June 22, 2024 at 4:30 pm
-June 11, 2024 at 12 pm
-May 22, 2024 at 12 pm
-May 11, 2024 at 9:30 pm
-May 10, 2024 at 12 pm
Client #4 was admitted January 25, 2024 and discharged March 11, 2024. A medication was prescribed to be given two times a day. The MAR was left blank for the following dates and times:
-March 10, 2024 at 7 am
An additional medication was prescribed to be given once daily at bedtime. The MAR was left blank for the following dates:
-March 9, 2024
An additional medication was prescribed to be given once daily at breakfast. The MAR was left blank for the following dates:
-March 10, 2024
Client #5 was admitted June 3, 2024 and still a current client. A medication was prescribed to be given two times a day. The MAR was left blank for the following dates and times:
-August 1, 2024 at 7 pm
-July 29, 2024 at 7 pm
-July 28, 2024 at 7 pm
-July 24, 2024 at 7 pm
An additional medication was prescribed to be given three times a day. The MAR was left blank for the following dates and times:
-July 28, 2024 at 2 pm
-July 27, 2024 at 2 pm
-July 26, 2024 at 2 pm
-July 25, 2024 at 2 pm
-July 24, 2024 at 2 pm
-July 21, 2024 at 2 pm
-July 13, 2024 at 2 pm
-July 10, 2024 at 2 pm
-July 2, 2024 at 2 pm
-June 30, 2024 at 9:30 pm
-June 23, 2024 at 2 pm
-June 20, 2024 at 8 am
-June 16, 2024 at 2 pm
-June 8, 2024 at 2 pm
-June 7, 2024 at 2 pm
An additional medication was prescribed to be given two times a day. The MAR was left blank for the following dates and times:
-July 22, 2024 at 9:30 pm
An additional medication was prescribed to be given once a day. The MAR was left blank for the following dates:
-July 14, 2024
An additional medication was prescribed to be given once a day. The MAR was left blank for the following dates:
-June 30, 2024
-June 29, 2024
-June 28, 2024
An additional medication was prescribed to be given once a day. The MAR was left blank for the following dates:
-July 2, 2024
-June 28, 2024
An additional medication was prescribed to be given four times a day. The MAR was left blank for the following dates and times:
-June 28, 2024 at 8 am, 12 pm, and 8 pm
-June 27, 2024 at 4 pm and 8 pm
-June 26, 2024 at 4 pm
Client #6 was admitted June 20, 2024 and still a current client. A medication was prescribed to be given three times a day. The MAR was left blank for the following dates and times:
-August 1, 2024 at 2 pm
-July 31, 2024 at 2 pm
-July 30, 2024 at 2 pm
-July 29, 2024 at 2 pm
-July 28, 2024 at 2 pm
-July 26, 2024 at 2 pm
-July 25, 2024 at 2 pm
-July 24, 2024 at 2 pm
-July 21, 2024 at 2 pm
-July 19, 2024 at 2 pm
-July 17, 2024 at 2 pm
-July 16, 2024 at 2 pm
-July 10, 2024 at 2 pm
-July 9, 2024 at 2 pm
-July 7, 2024 at 2 pm
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
1. Program Director informed all program staff of licensing review results and reminded staff of the requirement to document the appropriate information for every medication administration time (passed, missed, refused, not arrived, etc.). This information was reviewed again by the Program Director during the staff meeting held on 8/29/2024.
Person(s) Responsible: Program Director
Target Completion Date: Completed 8/8/2024 and 8/29/2024
2. Recovery Support Supervisor will run the "eMAR Missing Administration Events Report" weekly to identify missing documentation and provide a copy of the report to staff to follow up with deficiencies. Staff will have 48 hours to correct documentation barring no IT issues that would prevent it.
Person(s) Responsible: Recovery Support Supervisor
Target Completion Date: Ongoing
3. Program Director and other supervisors will document information and directives given about the eMAR and client rights regarding medication in supervision notes, memos, and staff meeting minutes.
Person(s) Responsible: Program Director, Clinical Supervisor, Recovery Support Supervisor
Target Completion Date: Ongoing
4. Recovery Support Professionals (RSP) will complete the "Assisting with Self-Administration of Medications: The Basics" and "Documenting the Monitoring of Self-Administration of Medications on the eMAR" trainings in Relias. Recovery Support Supervisor will monitor progress and ensure RSPs complete the assignments on time.
Person(s) Responsible: Recovery Support Supervisor
Target Completion Date: 9/20/2024
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one of one applicable client record.
Client #2 was admitted on March 19, 2024, and administratively discharged on June 4, 2024. There was no documentation of the facility notifying the client of the decision to terminate treatment in the client record.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
1. Program Director informed all program staff of licensing review results and reminded staff of the requirement to notify a client of the reason for an administrative discharge in writing using the "Termination of Treatment" form in the electronic health record. This information was reviewed again by the Program Director during the staff meeting held on 8/29/2024.
Person(s) Responsible: Program Director
Target Completion Date: Completed 8/8/2024 and 8/29/2024
2. Program Director and other supervisors will document information and directives given about administrative discharges and completing/providing the client with a copy of the "Termination of Treatment" document in supervision notes and staff meeting minutes.
Person(s) Responsible: Program Director, Clinical Supervisor, Recovery Support Supervisor
Target Completion Date: Ongoing
3. Program Director provided all staff with a copy of the Gaudenzia "PA 3.1 Workflow" (revision date 6/30/2024) which references requirements when a client is administratively discharged from the program.
Person(s) Responsible: Program Director
Target Completion Date: Completed 9/4/2024
4. Clinical Supervisor, Program Director, and CQI manager will seek documentation of the completion of the "Termination of Treatment" letter when a client is administratively discharged and ensure that counselors document that this form was provided to the client upon discharge during monthly/quarterly CQI chart audits. Clinical Supervisor will utilize supervision and performance improvement plans to address documentation deficiencies.
Person(s) Responsible: Clinical Supervisor, Program Director, CQI manager
Target Completion Date: Ongoing
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