Facility Evaluation Report

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Helping Hearts - Acacia Social Rehabilitation Facility to conduct a Case Management Visit. This Case Management Visit is in response to incident reports regarding medication errors on 12/18/23. LPA was greeted by Program Director, Lori Secord at the door and granted entry. LPA introduced self and stated purpose of the visit.

The Special/Unusual Incident Report, (SIR) was submitted to the Community Care Licensing Office on 12/19/23 reporting that on 12/18/23 it was discovered that Resident #1, (R1) was not given a 4pm dose of prescribed medications. R1's medical insurance - advice nurse, public guardian and the Program Director was notified upon the discovery.

According to staff interviews, the staff member responsible is a new staff member. When a new staff member starts working at the facility, they are provided hands on training then later a company wide new employee orientation which is more comprehensive. More comprehensive medication training specifically. Because this staff member has not been back on duty since the incident, Program Director has not had a chance to inquire about the specific details of the incident or provide the additional training to aid in preventing the occurrence in the future.

LPA previously completed a case management visit on 12/5/23 in relation to medication errors occurring on 11/22/23 and 11/27/23. Which also involved a new employee, only being provided hands on training before the comprehensive training at orientation could be provided. LPA and Program Director discussed methods of providing medication training new employees sooner than the company wide orientation can take place to aid in prevention of medication errors.