Facility Evaluation Report

Licensing Program Analyst (LPA) Dwayne Mason Jr. arrived at the facility for the purpose of conducting a Case Management Inspection to follow up on an incident report. LPA was greeted and granted entry by DSP Caitlyn Elliot. The Administrator Jason Ferraris arrived approximately 30 minutes after LPA's arrival.

LPA re-stated the purpose of the inspection. LPA is following up on an Incident Report received by Community Care Licensing (CCL) on 2/15/24. The incident was a medication error. The client (C1) was administered two 15mg Abilify pills in the morning. C1's Abilify prescription indicates that C1 take one pill in the morning and one pill in the evening. Administrator received instructions to monitor the client from the prescribing physician.

LPA collected copies of the following: 1. LIC 9020 - Registrar of Facility Clients, 2. C1's Admission Agreement, 3. The February 2024 Centrally Stored Medication and Destruction Record for C1, 4.Communication Log (which staff use to notate observations about clients during their shifts) from 2/15/24 to 2/29/24.

Based on record review, LPA noted that, in the 15 days following the medication error, facility staff only documented observational notes for C1 on the Facility Communication Log on 8 days compared the rest of the clients (each of whom had documented notes on 13 out of the 15 days).

Based on these records, LPA determined the facility did not thoroughly document observations regarding C1 following the medication error. Because of the lack of notes taken in the log, it cannot be verified if the facility staff monitored the client closely enough following the medication error. A deficiency is being issued.

Based on today inspection, one deficiency is being issued. An exit interview was conducted with the Administrator and a copy of this report was provided.