Facility Evaluation Report

At approximately 9:45AM, Licensing Program Analyst (LPA) Felias arrived unannounced to continue a Required 1 Year visit and met with Staff Member, Jonteja Fowler and Latanja Gibson. Manager of Program Operations, Kayla Hotchkiss, arrived at approximately at 10:35AM. Program Manager, Yvette Morgan, arrived at approximately 11:00AM. Facility is an Adult Residential Home that provides care and assistance for Adults with Disabilities. Facility has an approved fire clearance and capacity for 6 Ambulatory Clients. Upon arrival, LPA was informed that there were 6 clients in care, with 4 clients out of the community attending Day Program. LPA was also informed there were currently 2 staff members on site.

At approximately 10:00AM, LPA reviewed 3 client medication records with Staff Member, Program Manager and Manager of Program Operations. Facility chooses to use a Medication Administration Record (MAR) to record when medications are being administered to Clients. During medication review, LPA observed that two Client Medication Records did not match the amount of medication dispensed. Medication Records for Client 1 (C1) and Client 2 (C2) were not initialed or documented appropriately in the Facility's (MAR). Review of documentation indicated that C1 and C2 went home to see family, but that facility staff forgot to document that the medications were given to family members to administer for Clients off-site. LPA reviewed staff files and found no record of Medication Training being done. Facility was unable to provide documented proof to show that Facility Staff have had Medication Training as required (This Deficiency has been cited, see LIC809D, Regulation 80065(f)).

LPA also observed that Client 3 (C3) had a medication listed on the MAR that was to be given daily. This medication was observed to not have initials or be administered for the month of September 2023 but was initialed and administered for the month of August 2023. Per discussion with Program Manager and Manager of Program Operations, the Facility had been purchasing the medication as over-the counter. Facility conducted a Medication Audit in August 2023 and discovered that this medication was on the MAR but had not been filled by the pharmacy since 2018. Review of C3's file does not show an active order or discontinued order for this medication. C3's most updated physician orders does not list this medication as a prescription. Facility immediately contacted C3's pharmacy and physician to determine if this medication was still current or if it had been discontinued. As of today, Facility has yet to receive a response or clarification on whether or not C3 should continue with this medication (See Technical Advisory, Regulation 80075(b)(5)(A)).