Complaint Investigation Report

It was alleged that staff did not properly store medication. It was reported that medications were not being properly stored and secured. During the facility walkthrough, the LPA observed that the medication room was locked upon arrival. Additionally, inside the medication room, the medication cart was also observed to be locked. Interviews conducted with facility staff confirmed that the medication cart remains locked at all times, with the only exception being during active medication administration. Furthermore, the facility follows a schedule for distributing medications to clients during each shift. Based on observations and interviews conducted, the Department has insufficient evidence to support the allegation of “staff did not properly store medication”. Therefore, this allegation is deemed Unsubstantiated at this time.

It was also alleged that staff is not adequately trained. It was reported that facility staff are not adequately trained and unqualified to be administering medications to residents and safety drills are not being conducted quarterly. Per facility program, in Policy Title: Personnel Authorized for Medication Administration, it states under Procedure that “Medication is not administered by Casa staff. Residential Recovery Counselors are authorized to assist clients with medication self-administration…”. Additionally, per Policy Title: Ongoing Staff Training it states that “this program requires all staff complete 20 hours of training on an annual basis. There are certain trainings that are required on an annual basis and these trainings are incorporated into the program for ongoing staff training”. Record review of yearly staff trainings revealed that each staff member has at least 20 hours of training that includes medication training along with other training specific or related to their job specification. Additionally, record review of facility’s emergency disaster plan revealed that emergency disaster drills are being conducted quarterly as per regulation. Furthermore, record review and interviews conducted indicate that emergency disaster drills are being conducted at least once a month. Based on the information obtained and reviewed, the Department has insufficient evidence to support the allegation of “staff is not adequately trained”. Therefore, this allegation is deemed Unsubstantiated at this time.