Facility Evaluation Report

Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility and was greeted and granted entry by Lead Mental Health Tech (LM) Mac Carnahan. LPA then met with Erin Bull Program Director (PD). LPA stated the purpose of the inspection. LPA stated they are conducting a Case Management inspection to follow up on a medication error self-reported by the facility.

The incident report was received by Community Care Licensing (CCL) on 2/20/24. The report indicates:

1. Mental Health Coach (MH) gave client (C1) a 20mg Adderrall intended for another client (C2). C1 was supposed to take a 10mg Oxycodone at the time.

LPA interviewed the PD and LM and determined MH received their final write-up for this medication error. MH received two write-ups in the past for reasons unrelated to medication errors/administration. PD and LM stated MH underwent Medication Training on 2/20/24. According to the Written Warning, if MH makes another medication error, MH will be terminated. LPA reviewed alert charting notes regarding C1 electronically. The Alert Charting document was too large to print and could not be emailed due to security encryptions. Based on review of alert charting, LPA determined facility staff adequately monitored C1 following the medication error. C1 has since been discharged for reasons unrelated to the medication error.

LPA requested copies of the following documents:

1. C1's February 2024 MAR, 2. C1's Discharge Paperwork, 3. Staff Schedule for 2/19/24, 4.MH's Second Written Warning, 5. MH's Final Written Warning, 6. MH's signed Medication Training

Based on today's inspection, no deficiencies were cited. An exit interview was conducted and a copy of this report was provided to the facility.