Observations
Based on a review of medication storage inspection records, the facility failed to document quarterly inspections of the medication storage area.
The findings include:
Inspection records of the medication storage area for August 2012 through August 2013 were reviewed on August 8, 2013. The facility was due to complete quarterly inspections of the medication storage area no later than September 30, 2012, December 31, 2012, March 31, 2013 and June 30, 2013. The facility was only able to provide documentation of quarterly inspections for March 2013 and June 2013. The facility failed to document any quarterly inspections of the medication storage area in 2012.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
It was discovered that a new employee had accidentally shredded the control logs for 2012. At that time we placed a note in the medication storage inspection record stating the above had taken place. Since that event the behavioral tech who is responsible for the medication room completed the logs on a monthly basis. The Facility Director Monitors that this is being done. We are currently in compliance. |