INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on August 8, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site complaint investigation, Conewago Place 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(a) LICENSURE Medication Control
709.32. Medication control.
(a) Projects which furnish pharmaceutical services shall comply with all applicable Federal, State and local ordinances, statutes and regulations regarding the storing, compounding, administering or dispensing of medication.
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Observations
Based on a review of a client's medication, the facility failed to comply with the proper administering and dispensing of medication for client #1.
The findings include:
Based on a review of a client's medication container on August 8, 2013, the facility failed to comply with the storing, compounding, administering or dispensing of medication. According to client # 1's records, the client had been prescribed a medication. A review of the facility's medication container revealed a bottle with a hand written label with client # 1's name taped to the container.
The handwritten prescription for the medication was found on the client's medication chart. Interviews with staff confirmed that the client's prescription had not been filled because the client did not have funding to cover the expense of the medication. Staff interviewed confirmed they had supplied the medication to client # 1 with medication that had previously been prescribed for another client.
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Plan of Correction
Presciption for client was filled on 8/8/13. Program staff reveiewed the facility policy on administering and dispensing medications on 8/8/13.
Medical assistant will be responsible to ensure that policy is followed by program staff. Medical Assistant will monitor compliance with this facility policy on a weekly basis, starting 8/16/13.
Facility Director will monitor the facility policy on administering and dispensing of medication on a monthly basis, starting August 30, 2013, to ensure on-going compliance. |
709.53(a)(2) LICENSURE Medication records
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(2) Medication records.
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Observations
Based on a review of of the client's medication record, the facility failed to document a client's refusal to take medication.
The findings include;
Client # 1's medication record was reviewed on the electronic medication log. The client refused medication on July 25, July 26, July 27, July 28, and July 29, 2013. The refusals were not recorded on the client's medication log.
Where projects act as custodians of a client's medication, all medication being taken by a client whether prescribed by the project's physician or the client's private physician shall
be recorded in the chart indicating the name of the drug, dosage, and frequency of use.
Facility staff confirmed the missing documentation on client # 1's medication record..
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Plan of Correction
All program staff have been retrained on the proper documenting of any and all medications within the facility record/Facility Medical Documentation policy, on 8/16/13, by Medical Assistant.
Medical Assistant will monitor the facility medical documentation policy/protocol on a weekly basis, starting 8/23/13, to ensure on-going compliance.
Facility Director will monitor the facility medical documentation policy to ensure on-going compliance, beginning 8/30/13. |