| 2390.195(a)(11) | Individual #3's MAR's from August 2024 through June 2025 do not contain a diagnosis or purpose for the medication Perphenazine 8mg. | 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. | Plan of Correction for Regulation 2390.195(a)(11) :A medication record shall be kept including the following for each client for whom a prescription medication is administered: (11) Diagnosis or purpose for the medication, including pro re nata.
1) Director of Compliance trained Suncom's 2390 Medication Administration Trained staff that they are responsible to ensure for each client for whom a prescription medication is administered a medication record (MAR) is completed. The Medication Record (MAR) includes clients name, name of prescriber, drug allergies, name of medication, dosage form, dose of medication, route of medication, frequency of administration, administration times, diagnosis or purpose for the medication including pro re nata, date and time of the medication administration, name and initials of the person administering the medication, duration of treatment if applicable, and side effects of the medication if applicable. Medication Administration Trained staff are responsible to check a client¿s prescription at time of receiving medication that the prescription includes all components of 2390.195(a) regulation including diagnosis or purpose for medication. If the prescription medication does not include one of the medication record requirements staff are instructed to notify director or program specialist of what is required for the prescription medication.
-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 7/14/2025 & Attachment #2- Training Document)
2) Director of 2390 contacted Individual #3 family on 7/02/2025 to request a diagnosis or purpose for the medication Perphenazine 8mg from individual #3 physician. A doctor's note was received by Suncom on 07/08/2025 from individual's #3 physician that includes a diagnosis or purpose for the medication. (Attachment #3-Doctors note)
3) The diagnosis or purpose for the medication Perphenazine 8mg per the doctor notes was updated by 2390 Director to individual's #3 Medication Record (MAR). (Attachment #4 -July 2025 Corrected MAR & Attachment #5- Corrected MAR)
4) Director of 2390 emailed individual #3 Support Coordinator on 07/09/2025 to update the ISP with the medication's diagnosis or purpose of the medication. (Attachment #6- email) |
07/17/2025
| Implemented |