Facility Evaluation Report

On 12-19-23 at 1:28pm, Licensing Program Analyst (LPA) Michael Bilger arrived unannounced to conduct a case management visit regarding care plan updates and medication management. LPA met with lead direct support staff Amanda Duggirala and explained the purpose of the visit. LPA conducted brief interview with direct support staff and reviewed facility file documentation including updated care plan and transition plan for resident1 (R1), medication list for R1, and current staffing plan. LPA also conducted a facility observation. LPA observed 6 staff currently on duty for 2 clients in care. Facility has 3:1 staffing ratio for R1. Staffing plan reviewed indicates 7 staff on duty for AM and PM with 4 staff on duty for night shift while all clients are in care. Medication list for R1 has been updated to reflect new medication for R1. Medication list indicates a total of 6 new medication and dosage changes. No recent incidents regarding attempts to elope or increased agitation noted since R1's return to facility on 12-13-23. Facility staff reports R1 has been at baseline since return.

LPA also reviewed incident report dated 12-11-23. Incident report states that on 12-10-23, facility staff conducted a medication count and discovered R2's medication Divalproex was off by 1 count. Upon further discovery by facility staff it was determined that R2 received 1 dose of Divalproex instead of the prescribed 2, thus resulting in a medication error.

As a result of today's case management, citation is issued under Title 22, Division 6 and noted on LIC 809D. An exit interview was conducted with Amanda Duggirala and a copy of this report was provided to Amanda. Appeal rights provided.