Facility Evaluation Report

Licensing Program Analyst, LPA Noel Wolf Petersen, arrived unannounced to the facility to investigate an incident regarding a recent event where mulitple residents are out of the facility during a med pass, and clients were encouraged to reach out to staff if assistance was required. LPA met with administrator Chelsey Richardson, to explain the purpose of the visit.

Per administrator, medications are given as perscribed and a participation with the medications is volluntary, the facillities encouragement of the residents to make use of the medtech's ability to package a medication for the outside world is what the facility is currently doing.

LPA requested Mars for 7 clients, 3 some per the are administrator are habbitually not taking advantage of program per repeated encourgagment. Record review of the Mars of seven clients shows the clients repeatedly not taking advantage of the system as its in place. LPA asked for a documentation process for the stated intervention on the 624, at this moment, that would be a brief note on the mars incicating which staff is doing the encouraging for assistance with medication outside the building/calling ahead to the facility when the client is going to miss a medication pass

Mars review indicates this is a one off type behavior for 2 of the clients, and three who do this behavior every couple of weeks. 1 of 7 mars had a error that described a period of two weeks where the medication appeared to be held and after much explanation was revealed to be a typo. LPA is giving guidance that a audit of some random files once a quarter might catch this kind of mistake.

a copy of the report was read and given to the administrator, appeal rights were provided.