Facility Evaluation Report

Licensing Program Analyst (LPA) Cassie Yang arrived unannounced at the facility to conduct a case management visit regarding the semi-annual monitoring report conducted by Department of Developmental Services (DDS) on March 13, 2024. LPA met with Administrator and Licensee and explained the purpose of the visit.

Upon reviewing the report, LPA observed the following deficiency observed by DDS during their time of visit. The report stated C1 received a new medication order in February 2024 but based on file review of centrally stored log, it did not list C1's new medication order.

LPA, Licensee and Administrator discussed the incident that the new medication was inputted into the Medication Administration Record but just not in the log which list all the centrally stored medications. LPA was informed this error was due to the isolation when the facility tested positive for COVID-19.

Upon reviewing the report, LPA observed the following deficiency observed by DDS during their time of visit. The report stated C2 has a PRN order but the medication was not centrally stored.

Administrator informed LPA that the reason the medication was not centrally stored is because the medication has not been administered to C2 since November 2022. Administrator stated the pharmacy they are contracted with, is able to "stat" medication orders and have it ready within an hour if needed. Licensee informed LPA PRN replacement was not received due the excessive PRN medication waste when expired as refills has been made in the past, but not being administered.

Exit interview and a copy of the report provided.