| 2390.195(a)(11) | (repeat from 7/1/25 renewal inspection) The November 2025, December 2025, and January 2026 medication administration records for individual #3 do not include the diagnosis for the noon medication, Metformin 850mg tablet. | A medication record shall be kept, including the following for each client for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | 1. The Director of Compliance trained Suncom's 2390 Director and Medication Administration trained staff on their responsibility to ensure that for each client who is prescribed medication a complete Medication Administration Record (MAR) is created and maintained. Medication Administration trained staff are responsible for writing or typing the MAR in full and ensuring all required information is complete and accurate prior to implementation of the medication.
-The Medication Administration Record (MAR) must include the client's name, name of the prescriber, documented drug allergies, name of the medication, dosage form, dose, route of administration, frequency of administration, administration times, diagnosis or purpose for the medication (including pro re nata medications), date and time of medication administration, name and initials of the person administering the medication, duration of treatment if applicable, and side effects of the medication, if applicable.
-A Medication Administration trained staff has the responsibility of writing or typing the clients' Medication Administration Records (MARs) forms will be required to have all sections of the MAR completed, including the medication diagnosis/purpose. Prior to implementation of the MAR, the MAR form will be reviewed by a medication administration trained staff to ensure accuracy and completeness. A Medication Administration trained staff has the responsibility that prior to passing medications of checking the MAR are accurate prior to administration. If diagnosis or purpose for the medication is not properly documented according to regulation 2390.195(a)(11), the diagnosis or purpose of the medication will be added to the client's medication record (s) (MAR's) in the proper format and to include date and initials of entry.
-A Medication Administration trained staff will review all MARs in the Bloomsburg 2390 Program by 1/29/2026 to ensure diagnosis or purpose for the medication is properly documented on the client(s) MAR's, if diagnosis or purpose for the medication is not properly documented according to the regulation 2390.195(a)(11), the diagnosis or purpose of the medication will be added to the client's medication record (s) (MAR's) in the proper format and to include date and initials of entry.
------Medication Administration Trained Staff were trained in the requirement of regulation 2390.195 (a)(11) Training memo created by Director of Compliance. (Attachment #1- Training Sheet completed & Attachment #2- Training Document)
2. The Medication Administration Records (MAR's) were corrected for individual #3 to include the diagnosis for the noon medication, Metformin 850mg tables for the MAR's of November 2025, December 2025, and January 2026.
·------The diagnosis for the medication Metformin was corrected by 2390 Director to individual's #3 Medication Record (MAR). (Attachment #3 Corrected MAR- & Attachment #4- November 2025 Corrected MAR, and Attachment #5- December 2025 Corrected MAR, and Attachment #6- January 2026 Corrected MAR, |
01/30/2026
| Implemented |