| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(g) | On 9/18/2024 11:25AM, the only bathrooms in the home are ensuite to Individual #1's bedroom and Individual #2's bedroom. There are not doors to the bathrooms through the common areas of the home. As per Chief Executive Officer #1, staff persons use Individual #1's bedroom to access the ensuite bathroom in Individual #1's bedroom. | A bedroom may not be used by other individuals or staff persons as a regular or frequent passageway to another part of the home or to the outdoors. | The Operations Manager submitted a Request for Regulatory Waiver on 9/27/2024. In addition, the Operations Manager submitted a request to the apartment complex¿s management team to request an approval for a change in apartment structure/layout. A privacy curtain was placed in the hallway of the home until approval/denial is received. CEO continues to research a better removable door option for the small space in the hallway leading to the individual¿s room that will not impede the individual exiting in a safe manner, that can lock, and the individual will be able to operate. The staff continue to speak with individual about the possibility of moving as he does not want to change his living arrangement. |
09/27/2024
| Implemented |
| 6400.32(c) | On 7/9/2024 Individual #1's order for Ozempic 2mg/3mL with instructions to administer 0.25mg every 7 days was changed to a dose of 4mg/3mL with instructions to administer 0.75mL every 7 days. Individual #1's Medication Administration Records were not updated to reflect this change and Individual #1 continued to be administered the wrong dose once weekly from 7/9/2024 through 9/18/2024. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | The Certified Investigator submitted the Medication error to EIM under #9487732. (9/20/2024)
The current Certified Investigator Policy was reviewed with the Program Manager for proper filing requirements. (9/24/2024)
The Operations Manager added the Medication Deliveries/ Out of Medications/ Disposing Medications protocol to reflect the proper reporting procedures for medications errors.
The Program Manager, Program Specialist, and Residential Supervisors were trained on this new protocol. (9/30-10/3/2024)
Medication Deliveries: Medications are delivered to the main office per a schedule set by PDC pharmacy. The following protocol must be followed to ensure compliance with the regulations 6400.166:
1. Every 3rd Thursday of the month, Supervisors are to ensure that medication lock boxes are present at the office (after 12pm med pass).
2. All medications must be counted to ensure the cycle count is accurate. Supervisors are to utilize a printed MAR and the Packaging slip to complete this count.
3. When reviewing the delivered medications, the following items must be reviewed to ensure the Medication Label and MAR match exactly:
a. Individual Name b. Name of the Prescriber c. Name of Medication
d. Strength of Medication e. Dosage form f. Dose of medication
g. Route of Administration h. Frequency of administration i. Diagnosis or purpose for the medication, including pro re nata J. Brand Name k. time of administration
4. Any incorrect information found on the MAR must be submitted to the Program Specialist for corrections. These corrections must be completed on the same day.
5. This process must be completed every 3rd Thursday at the Program Meeting.
6. Supervisors will sign off on the Medications form monthly verifying that they have completed the steps above.
7. Medications will be delivered back to the homes before the next med pass at 4pm.
8. Ozempic and any subcutaneous medications will be kept at the office for safekeeping and proper administration.
9. Medication Errors are required to be submitted in EIM within 72 hours and reported to the Individuals designee. |
09/27/2024
| Implemented |
| 6400.163(h) | On 9/18/2024 at 11:06am, Ozempic Inj 2mg/3mL prescribed to Individual #1 with instructions to inject 0.25mg under the skin every 7 days for diabetes was observed on site in the residential home. This medication was discontinued by the prescriber on 7/9/2024. The medication remained in the home. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The Operations Manager added the Medication Deliveries/ Out of Medications/ Disposing Medications are disposed of when treatment is completed, or medications are discontinued. (9/24/2024)
The Program Manager, Program Specialist, and Residential Supervisors were trained on this new protocol. (9/30-10/3/2024)
Disposing of Medications
1. When medications are discontinued by the Licensed professional, the Program Specialist will ensure the medication is removed from the home on the same day.
2. All medications bubble packs must be removed from the houses once they have been administered.
3. The Program Specialist and Program Manager will utilize the RX Destroyer to dispose of any discontinued medications.
4. The disposal form will be completed and signed.
5. All medication bubble packs will be destroyed to ensure privacy of the Individuals. |
09/27/2024
| Implemented |
| 6400.165(c) | On 7/9/2024 Individual #1's order for Ozempic 2mg/3mL with instructions to administer 0.25mg every 7 days was changed to a dose of 4mg/3mL with instructions to administer 0.75mL every 7 days. Individual #1's Medication Administration Records were not updated to reflect this change. Individual #1 continued to be administered the wrong dose once weekly from 7/9/2024 through 9/18/2024. | A prescription medication shall be administered as prescribed. | Staff were retrained on the 5 rights of medication administration. All staff must check all 5 rights before administering a medication to ensure the medication is giving as per MAR instruction.
The Program Specialist and Operations Manager participated in a Therap training that taught how to utilize the Pharmacy interface for adding medications to the MAR and to also ensure the diagnosis is located on the MAR.
The Operations Manager added the Medication Deliveries/ Out of Medications/ Disposing Medications protocol to ensure the MAR/Label match exactly. (9/24/2024)
The Program Manager, Program Specialist, and Residential Supervisors were trained on this new protocol. (9/30-10/3/2024)
Medication Deliveries: Medications are delivered to the main office per a schedule set by PDC pharmacy. The following protocol must be followed to ensure compliance with the regulations 6400.166:
1. Every 3rd Thursday of the month, Supervisors are to ensure that medication lock boxes are present at the office (after 12pm med pass).
2. All medications must be counted to ensure the cycle count is accurate. Supervisors are to utilize a printed MAR and the Packaging slip to complete this count.
3. When reviewing the delivered medications, the following items must be reviewed to ensure the Medication Label and MAR match exactly:
a. Individual Name b. Name of the Prescriber c. Name of Medication
d. Strength of Medication e. Dosage form f. Dose of medication
g. Route of Administration h. Frequency of administration i. Diagnosis or purpose for the medication, including pro re nata J. Brand Name k. time of administration
4. Any incorrect information found on the MAR must be submitted to the Program Specialist for corrections. These corrections must be completed on the same day.
5. This process must be completed every 3rd Thursday at the Program Meeting.
6. Supervisors will sign off on the Medications form monthly verifying that they have completed the steps above.
7. Medications will be delivered back to the homes before the next med pass at 4pm.
8. Ozempic and any subcutaneous medications will be kept at the office for safekeeping and proper administration.
9. Medication Errors are required to be submitted in EIM within 72 hours and reported to the Individuals designee.
The Program Manager, Program Specialist, and Residential Supervisors were trained on this new protocol. (9/30-10/3/2024) |
09/27/2024
| Implemented |
| 6400.166(a)(4) | Individual #1 is prescribed Ozempic Inj 4mg/3mL with instructions to inject 0.75mL (1mg total) under the skin every 7 days for diabetes. Individual #1's September 2024 Medication Administration record did not include the name of the medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | Staff were retrained on the 5 rights of medication administration. All staff must check all 5 rights before administering a medication to ensure the medication is giving as per MAR instruction . The Program Specialist and Operations Manager participated in a Therap training that taught how to utilize the Pharmacy interface for adding medications to the MAR and to also ensure the diagnosis is located on the MAR.
The Operations Manager added the Medication Deliveries/ Out of Medications/ Disposing Medications protocol to ensure the MAR/Label match exactly. (9/24/2024)
The Program Manager, Program Specialist, and Residential Supervisors were trained on this new protocol. (9/30-10/3/2024)
Medication Deliveries: Medications are delivered to the main office per a schedule set by PDC pharmacy. The following protocol must be followed to ensure compliance with the regulations 6400.166:
1. Every 3rd Thursday of the month, Supervisors are to ensure that medication lock boxes are present at the office (after 12pm med pass).
2. All medications must be counted to ensure the cycle count is accurate. Supervisors are to utilize a printed MAR and the Packaging slip to complete this count.
3. When reviewing the delivered medications, the following items must be reviewed to ensure the Medication Label and MAR match exactly:
a. Individual Name b. Name of the Prescriber c. Name of Medication
d. Strength of Medication e. Dosage form f. Dose of medication
g. Route of Administration h. Frequency of administration i. Diagnosis or purpose for the medication, including pro re nata J. Brand Name k. time of administration
4. Any incorrect information found on the MAR must be submitted to the Program Specialist for corrections. These corrections must be completed on the same day.
5. This process must be completed every 3rd Thursday at the Program Meeting.
6. Supervisors will sign off on the Medications form monthly verifying that they have completed the steps above.
7. Medications will be delivered back to the homes before the next med pass at 4pm.
8. Ozempic and any subcutaneous medications will be kept at the office for safekeeping and proper administration.
9. Medication Errors are required to be submitted in EIM within 72 hours and reported to the Individuals designee.
The Program Manager, Program Specialist, and Residential Supervisors were trained on this new protocol. (9/30-10/3/2024) |
09/27/2024
| Implemented |
| 6400.166(a)(5) | Individual #1 is prescribed Ozempic Inj 4mg/3mL with instructions to inject 0.75mL (1mg total) under the skin every 7 days for diabetes. Individual #1's September 2024 Medication Administration record did not include the strength of the medication. Individual #2 is prescribed Nicotine 4mg Chewing Gun to be administered pro re nata. The medication that was available to Individual #2 on site was Nicotine Mini Lozenge 2mg. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | Staff were retrained on the 5 rights of medication administration. All staff must check all 5 rights before administering a medication to ensure the medication is giving as per MAR instruction. The Program Specialist and Operations Manager participated in a Therap training that taught how to utilize the Pharmacy interface for adding medications to the MAR and to also ensure the diagnosis is located on the MAR.
The Operations Manager added the Medication Deliveries/ Out of Medications/ Disposing Medications protocol to ensure the MAR/Label match exactly. (9/24/2024)
The Program Manager, Program Specialist, and Residential Supervisors were trained on this new protocol. (9/30-10/3/2024)
Medication Deliveries: Medications are delivered to the main office per a schedule set by PDC pharmacy. The following protocol must be followed to ensure compliance with the regulations 6400.166:
1. Every 3rd Thursday of the month, Supervisors are to ensure that medication lock boxes are present at the office (after 12pm med pass).
2. All medications must be counted to ensure the cycle count is accurate. Supervisors are to utilize a printed MAR and the Packaging slip to complete this count.
3. When reviewing the delivered medications, the following items must be reviewed to ensure the Medication Label and MAR match exactly:
a. Individual Name b. Name of the Prescriber c. Name of Medication
d. Strength of Medication e. Dosage form f. Dose of medication
g. Route of Administration h. Frequency of administration i. Diagnosis or purpose for the medication, including pro re nata J. Brand Name k. time of administration
4. Any incorrect information found on the MAR must be submitted to the Program Specialist for corrections. These corrections must be completed on the same day.
5. This process must be completed every 3rd Thursday at the Program Meeting.
6. Supervisors will sign off on the Medications form monthly verifying that they have completed the steps above.
7. Medications will be delivered back to the homes before the next med pass at 4pm.
8. Ozempic and any subcutaneous medications will be kept at the office for safekeeping and proper administration.
9. Medication Errors are required to be submitted in EIM within 72 hours and reported to the Individuals designee.
The Program Manager, Program Specialist, and Residential Supervisors were trained on this new protocol. (9/30-10/3/2024) |
09/27/2024
| Implemented |
| 6400.166(a)(6) | Individual #1 is prescribed Ozempic Inj 4mg/3mL with instructions to inject 0.75mL (1mg total) under the skin every 7 days for diabetes. Individual #1's September 2024 Medication Administration record did not include the dosage form of the medication. Individual #2 is prescribed Nicotine 4mg Chewing Gun to be administered pro re nata. The medication that was available to Individual #2 on site was Nicotine Mini Lozenge 2mg. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | Staff were retrained on the 5 rights of medication administration. All staff must check all 5 rights before administering a medication to ensure the medication is being given as per MAR instruction. The Program Specialist and Operations Manager participated in a Therap training that taught how to utilize the Pharmacy interface for adding medications to the MAR and to also ensure the diagnosis is located on the MAR.
The Operations Manager added the Medication Deliveries/ Out of Medications/ Disposing Medications protocol to ensure the MAR/Label match exactly. (9/24/2024)
The Program Manager, Program Specialist, and Residential Supervisors were trained on this new protocol. (9/30-10/3/2024)
Medication Deliveries: Medications are delivered to the main office per a schedule set by PDC pharmacy. The following protocol must be followed to ensure compliance with the regulations 6400.166:
1. Every 3rd Thursday of the month, Supervisors are to ensure that medication lock boxes are present at the office (after 12pm med pass).
2. All medications must be counted to ensure the cycle count is accurate. Supervisors are to utilize a printed MAR and the Packaging slip to complete this count.
3. When reviewing the delivered medications, the following items must be reviewed to ensure the Medication Label and MAR match exactly:
a. Individual Name b. Name of the Prescriber c. Name of Medication
d. Strength of Medication e. Dosage form f. Dose of medication
g. Route of Administration h. Frequency of administration i. Diagnosis or purpose for the medication, including pro re nata J. Brand Name k. time of administration
4. Any incorrect information found on the MAR must be submitted to the Program Specialist for corrections. These corrections must be completed on the same day.
5. This process must be completed every 3rd Thursday at the Program Meeting.
6. Supervisors will sign off on the Medications form monthly verifying that they have completed the steps above.
7. Medications will be delivered back to the homes before the next med pass at 4pm.
8. Ozempic and any subcutaneous medications will be kept at the office for safekeeping and proper administration.
9. Medication Errors are required to be submitted in EIM within 72 hours and reported to the Individuals designee.
The Program Manager, Program Specialist, and Residential Supervisors were trained on this new protocol. (9/30-10/3/2024) |
09/27/2024
| Implemented |
| 6400.166(a)(7) | Individual #1 is prescribed Ozempic Inj 4mg/3mL with instructions to inject 0.75mL (1mg total) under the skin every 7 days for diabetes. Individual #1's September 2024 Medication Administration record did not include the dose of the medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | Staff were retrained on the 5 rights of medication administration. All staff must check all 5 rights before administering a medication to ensure the medication is being given as per MAR instruction. The Program Specialist and Operations Manager participated in a Therap training that taught how to utilize the Pharmacy interface for adding medications to the MAR and to also ensure the diagnosis is located on the MAR.
The Operations Manager added the Medication Deliveries/ Out of Medications/ Disposing Medications protocol to ensure the MAR/Label match exactly. (9/24/2024)
The Program Manager, Program Specialist, and Residential Supervisors were trained on this new protocol. (9/30-10/3/2024)
Medication Deliveries: Medications are delivered to the main office per a schedule set by PDC pharmacy. The following protocol must be followed to ensure compliance with the regulations 6400.166:
1. Every 3rd Thursday of the month, Supervisors are to ensure that medication lock boxes are present at the office (after 12pm med pass).
2. All medications must be counted to ensure the cycle count is accurate. Supervisors are to utilize a printed MAR and the Packaging slip to complete this count.
3. When reviewing the delivered medications, the following items must be reviewed to ensure the Medication Label and MAR match exactly:
a. Individual Name b. Name of the Prescriber c. Name of Medication
d. Strength of Medication e. Dosage form f. Dose of medication
g. Route of Administration h. Frequency of administration i. Diagnosis or purpose for the medication, including pro re nata J. Brand Name k. time of administration
4. Any incorrect information found on the MAR must be submitted to the Program Specialist for corrections. These corrections must be completed on the same day.
5. This process must be completed every 3rd Thursday at the Program Meeting.
6. Supervisors will sign off on the Medications form monthly verifying that they have completed the steps above.
7. Medications will be delivered back to the homes before the next med pass at 4pm.
8. Ozempic and any subcutaneous medications will be kept at the office for safekeeping and proper administration.
9. Medication Errors are required to be submitted in EIM within 72 hours and reported to the Individuals designee.
The Program Manager, Program Specialist, and Residential Supervisors were trained on this new protocol. (9/30-10/3/2024) |
09/27/2024
| Implemented |
| 6400.166(a)(8) | Individual #1 is prescribed Ozempic Inj 4mg/3mL with instructions to inject 0.75mL (1mg total) under the skin every 7 days for diabetes. Individual #1#1's September 2024 Medication Administration Record did not include the route of administration. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | Staff were retrained on the 5 rights of medication administration. All staff must check all 5 rights before administering a medication to ensure the medication is being given as per MAR instruction. The Program Specialist and Operations Manager participated in a Therap training that taught how to utilize the Pharmacy interface for adding medications to the MAR and to also ensure the diagnosis is located on the MAR.
The Operations Manager added the Medication Deliveries/ Out of Medications/ Disposing Medications protocol to ensure the MAR/Label match exactly. (9/24/2024)
The Program Manager, Program Specialist, and Residential Supervisors were trained on this new protocol. (9/30-10/3/2024)
Medication Deliveries: Medications are delivered to the main office per a schedule set by PDC pharmacy. The following protocol must be followed to ensure compliance with the regulations 6400.166:
1. Every 3rd Thursday of the month, Supervisors are to ensure that medication lock boxes are present at the office (after 12pm med pass).
2. All medications must be counted to ensure the cycle count is accurate. Supervisors are to utilize a printed MAR and the Packaging slip to complete this count.
3. When reviewing the delivered medications, the following items must be reviewed to ensure the Medication Label and MAR match exactly:
a. Individual Name b. Name of the Prescriber c. Name of Medication
d. Strength of Medication e. Dosage form f. Dose of medication
g. Route of Administration h. Frequency of administration i. Diagnosis or purpose for the medication, including pro re nata J. Brand Name k. time of administration
4. Any incorrect information found on the MAR must be submitted to the Program Specialist for corrections. These corrections must be completed on the same day.
5. This process must be completed every 3rd Thursday at the Program Meeting.
6. Supervisors will sign off on the Medications form monthly verifying that they have completed the steps above.
7. Medications will be delivered back to the homes before the next med pass at 4pm.
8. Ozempic and any subcutaneous medications will be kept at the office for safekeeping and proper administration.
9. Medication Errors are required to be submitted in EIM within 72 hours and reported to the Individuals designee.
The Program Manager, Program Specialist, and Residential Supervisors were trained on this new protocol. (9/30-10/3/2024) |
09/27/2024
| Implemented |
| 6400.166(a)(9) | Individual #1 is prescribed Ozempic Inj 4mg/3mL with instructions to inject 0.75mL (1mg total) under the skin every 7 days for diabetes. Individual #1's September 2024 Medication Administration Record did not include the frequency of administration. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | Staff were retrained on the 5 rights of medication administration. All staff must check all 5 rights before administering a medication to ensure the medication is being given as per MAR instruction. The Program Specialist and Operations Manager participated in a Therap training that taught how to utilize the Pharmacy interface for adding medications to the MAR and to also ensure the diagnosis is located on the MAR.
The Operations Manager added the Medication Deliveries/ Out of Medications/ Disposing Medications protocol to ensure the MAR/Label match exactly. (9/24/2024)
The Program Manager, Program Specialist, and Residential Supervisors were trained on this new protocol. (9/30-10/3/2024)
Medication Deliveries: Medications are delivered to the main office per a schedule set by PDC pharmacy. The following protocol must be followed to ensure compliance with the regulations 6400.166:
1. Every 3rd Thursday of the month, Supervisors are to ensure that medication lock boxes are present at the office (after 12pm med pass).
2. All medications must be counted to ensure the cycle count is accurate. Supervisors are to utilize a printed MAR and the Packaging slip to complete this count.
3. When reviewing the delivered medications, the following items must be reviewed to ensure the Medication Label and MAR match exactly:
a. Individual Name b. Name of the Prescriber c. Name of Medication
d. Strength of Medication e. Dosage form f. Dose of medication
g. Route of Administration h. Frequency of administration i. Diagnosis or purpose for the medication, including pro re nata J. Brand Name k. time of administration
4. Any incorrect information found on the MAR must be submitted to the Program Specialist for corrections. These corrections must be completed on the same day.
5. This process must be completed every 3rd Thursday at the Program Meeting.
6. Supervisors will sign off on the Medications form monthly verifying that they have completed the steps above.
7. Medications will be delivered back to the homes before the next med pass at 4pm.
8. Ozempic and any subcutaneous medications will be kept at the office for safekeeping and proper administration.
9. Medication Errors are required to be submitted in EIM within 72 hours and reported to the Individuals designee.
The Program Manager, Program Specialist, and Residential Supervisors were trained on this new protocol. (9/30-10/3/2024) |
09/27/2024
| Implemented |
| 6400.166(a)(10) | Individual #1 is prescribed Ozempic Inj 4mg/3mL with instructions to inject 0.75mL (1mg total) under the skin every 7 days for diabetes. Individual #1's September 2024 Medication Administration Record did not include the administration times. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | Staff were retrained on the 5 rights of medication administration. All staff must check all 5 rights before administering a medication to ensure the medication is giving as per MAR instruction. The Program Specialist and Operations Manager participated in a Therap training that taught how to utilize the Pharmacy interface for adding medications to the MAR and to also ensure the diagnosis is located on the MAR.
The Operations Manager added the Medication Deliveries/ Out of Medications/ Disposing Medications protocol to ensure the MAR/Label match exactly. (9/24/2024)
The Program Manager, Program Specialist, and Residential Supervisors were trained on this new protocol. (9/30-10/3/2024)
Medication Deliveries: Medications are delivered to the main office per a schedule set by PDC pharmacy. The following protocol must be followed to ensure compliance with the regulations 6400.166:
1. Every 3rd Thursday of the month, Supervisors are to ensure that medication lock boxes are present at the office (after 12pm med pass).
2. All medications must be counted to ensure the cycle count is accurate. Supervisors are to utilize a printed MAR and the Packaging slip to complete this count.
3. When reviewing the delivered medications, the following items must be reviewed to ensure the Medication Label and MAR match exactly:
a. Individual Name b. Name of the Prescriber c. Name of Medication
d. Strength of Medication e. Dosage form f. Dose of medication
g. Route of Administration h. Frequency of administration i. Diagnosis or purpose for the medication, including pro re nata J. Brand Name k. time of administration
4. Any incorrect information found on the MAR must be submitted to the Program Specialist for corrections. These corrections must be completed on the same day.
5. This process must be completed every 3rd Thursday at the Program Meeting.
6. Supervisors will sign off on the Medications form monthly verifying that they have completed the steps above.
7. Medications will be delivered back to the homes before the next med pass at 4pm.
8. Ozempic and any subcutaneous medications will be kept at the office for safekeeping and proper administration.
9. Medication Errors are required to be submitted in EIM within 72 hours and reported to the Individuals designee.
The Program Manager, Program Specialist, and Residential Supervisors were trained on this new protocol. (9/30-10/3/2024) |
09/27/2024
| Implemented |
| 6400.166(a)(11) | Individual #1 is prescribed Ozempic Inj 4mg/3mL with instructions to inject 0.75mL (1mg total) under the skin every 7 days for diabetes. Individual #1's September 2024 Medication Administration Record did not include the diagnosis or purpose for the medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Staff were retrained on the 5 rights of medication administration. All staff must check all 5 rights before administering a medication to ensure the medication is giving as per MAR instruction. The Program Specialist and Operations Manager participated in a Therap training that taught how to utilize the Pharmacy interface for adding medications to the MAR and to also ensure the diagnosis is located on the MAR.
The Operations Manager added the Medication Deliveries/ Out of Medications/ Disposing Medications protocol to ensure the MAR/Label match exactly. (9/24/2024)
The Program Manager, Program Specialist, and Residential Supervisors were trained on this new protocol. (9/30-10/3/2024)
Medication Deliveries: Medications are delivered to the main office per a schedule set by PDC pharmacy. The following protocol must be followed to ensure compliance with the regulations 6400.166:
1. Every 3rd Thursday of the month, Supervisors are to ensure that medication lock boxes are present at the office (after 12pm med pass).
2. All medications must be counted to ensure the cycle count is accurate. Supervisors are to utilize a printed MAR and the Packaging slip to complete this count.
3. When reviewing the delivered medications, the following items must be reviewed to ensure the Medication Label and MAR match exactly:
a. Individual Name b. Name of the Prescriber c. Name of Medication
d. Strength of Medication e. Dosage form f. Dose of medication
g. Route of Administration h. Frequency of administration i. Diagnosis or purpose for the medication, including pro re nata J. Brand Name k. time of administration
4. Any incorrect information found on the MAR must be submitted to the Program Specialist for corrections. These corrections must be completed on the same day.
5. This process must be completed every 3rd Thursday at the Program Meeting.
6. Supervisors will sign off on the Medications form monthly verifying that they have completed the steps above.
7. Medications will be delivered back to the homes before the next med pass at 4pm.
8. Ozempic and any subcutaneous medications will be kept at the office for safekeeping and proper administration.
9. Medication Errors are required to be submitted in EIM within 72 hours and reported to the Individuals designee.
The Program Manager, Program Specialist, and Residential Supervisors were trained on this new protocol. (9/30-10/3/2024) |
09/27/2024
| Implemented |
| 6400.166(b) | Mirtazapine, prescribed to Individual #2, was increased from 15mg to 30mg on 8/29/2024. On 9/18/2024, both strengths remained on Individual #2's September 2024 Medication Administration Record and both were initialled as at 8:00PM from 9/1/2024 through 9/17/2024. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Staff were retrained on the 5 rights of medication administration. All staff must check all 5 rights before administering a medication to ensure the medication is giving as per MAR instruction .
The Program Specialist and Operations Manager participated in a Therap training that taught how to utilize the Pharmacy interface for adding medications to the MAR and to also ensure the diagnosis is located on the MAR.
The Operations Manager added the Medication Deliveries/ Out of Medications/ Disposing Medications protocol to ensure the MAR/Label match exactly. (9/24/2024)
The Program Manager, Program Specialist, and Residential Supervisors were trained on this new protocol. (9/30-10/3/2024)
Medication Deliveries: Medications are delivered to the main office per a schedule set by PDC pharmacy. The following protocol must be followed to ensure compliance with the regulations 6400.166:
1. Every 3rd Thursday of the month, Supervisors are to ensure that medication lock boxes are present at the office (after 12pm med pass).
2. All medications must be counted to ensure the cycle count is accurate. Supervisors are to utilize a printed MAR and the Packaging slip to complete this count.
3. When reviewing the delivered medications, the following items must be reviewed to ensure the Medication Label and MAR match exactly:
a. Individual Name b. Name of the Prescriber c. Name of Medication
d. Strength of Medication e. Dosage form f. Dose of medication
g. Route of Administration h. Frequency of administration i. Diagnosis or purpose for the medication, including pro re nata J. Brand Name k. time of administration
4. Any incorrect information found on the MAR must be submitted to the Program Specialist for corrections. These corrections must be completed on the same day.
5. This process must be completed every 3rd Thursday at the Program Meeting.
6. Supervisors will sign off on the Medications form monthly verifying that they have completed the steps above.
7. Medications will be delivered back to the homes before the next med pass at 4pm.
8. Ozempic and any subcutaneous medications will be kept at the office for safekeeping and proper administration.
9. Medication Errors are required to be submitted in EIM within 72 hours and reported to the Individuals designee.
The Program Manager, Program Specialist, and Residential Supervisors were trained on this new protocol. (9/30-10/3/2024) |
09/27/2024
| Implemented |
| 6400.167(a)(3) | On 7/9/2024 Individual #1's order for Ozempic 2mg/3mL with instructions to administer 0.25mg every 7 days was changed to a dose of 4mg/3mL with instructions to administer 0.75mL every 7 days. The individual #1's Medication Administration Record was not updated to reflect this change. Individual #1 continued to receive an incorrect dose once weekly from 7/9/2024 through 9/18/2024. | Medication errors include the following: Administration of the wrong dose of medication. | The Program Manager submitted the following medication errors into EIM: 9493309,
9493320, 9493324, 9493308, 9493318, 9493317, 9493333, 9493338, 9493342.
The Operations Manager added a Signup agreement that documented the proper medication administration and documentation process. DSPs received this training from their House Supervisors, and it is reviewed every time they log into Therap to administer medications.
Title: Electronic MAR Documenting
Details: When Administering medications please follow these steps:
Part 1 Preparation
1. Identify Individual and Medication Box
2. Prepare a clean space to pop the medications
3. Gather medication cups, water, etc.
4. Open the medication box
5. Wash Hands
Part 2 Administration
1. Check 1: Check the MAR and the Medication Label
2. Check 2: Check the MAR and the Medication Label
3. Check 3: Check the MAR and the Medication Label
4. Administer the Medication
5. Observe after administration to ensure medication has been swallowed
Part 3 Completion
1. Recheck the Rights (IMDTR)
2. Document on the MAR and Bubble pack
3. Put away the medication
4. Wash Hands
5. Observe for Effects
Please contact William H (PM with any questions) 412.699.912 |
09/27/2024
| Implemented |