|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.136(a)(4) | Individual #1 is prescribed Loratadine 10 mg tablets (more commonly known as Claritin). The name of the medication is not recorded on Individual #1's Medication Administration Record for June 2024. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | Clarification from the 6400 Regulatory Compliance Guide:
Discussion: Proper medication record use is critical, as it: ¿ Creates a record of proper medication administration, ¿ Allows physicians and emergency personnel to know when a medication was last administered; and ¿ Creates a system to account for medications, especially controlled substances. What medications must be recorded on the medication record? ¿ Prescription medications ¿ Over the counter (OTC) medications ¿ Vitamins ¿ Complementary and alternative medications (CAM) ¿ PRN (Pro re nata) medications What medications are not required to be recorded on the medication record? ¿ Nutritional supplements ¿ Special diets PRN medications must be entered into the medication record so that it is available immediately should it be needed. A medication record should always reflect all prescribed medications. Examples of CAM include acupuncture, herbal supplements, and cannabidiol products that contain less than 0.3 percent THC. It is very important that CAM be recorded on the medication record, as these products may have side effects when used with prescribed medications. Aromatherapy is not considered to be CAM and does not need to be recorded on the MR. Nutritional supplements (nutrition shakes, protein powders, etc.) and special diets do not need to be recorded on the medication record, but the home must be aware of and provide nutritional supplements and special diets if ordered by a physician. It is recommended that any nutritional supplement or specific diet recommendation that requires the counting or calories, carbs, fluid ounces, and related information be recorded in the individual¿s assessment. Remember, homes are responsible for ensuring that individuals may take OTC medications without causing allergic reactions or impacting prescription medications prescribed to the individual. What administration information must be recorded on the medication record? If several pills are packaged together in one blister pack and administered together at the same time, information for each pill in the blister must be listed individually on the medication record; the reason for this relates to individuals¿ right to refuse medications. If a person refuses to take a pill or if one or more of the pills in the blister is not administered, the home must have a means of documenting the refusal. The administration of a medication by a source outside of the home (such as a monthly scheduled injection in a physician¿s office or medication administered while visiting family) should not be documented on the medication record for the home. Only medication given by staff members of the home are to be documented on the medication record. However, any documentation given to the individual as a result of receiving administration of a medication by a source outside of the home (such as invoices, doctor¿s notes; etc.) should be kept in the individual¿s record for reference purposes. Diagnosis must be included because the same medications may be used to treat different conditions. If there is a specific time of administration listed on the medications record, such as 8:00 AM and 8:00 PM, the actual clock time of each administration is not required to be recorded. The record can simply include staff initials. This means the medication was given within 60 minutes plus or minus the specified time. If the medication record does not list a clock time (such as am, pm, at breakfast, after lunch) the exact time of administration must be recorded. The generic use of the word ¿administered¿ may contribute to a potential misunderstanding. The medication administration course uses the word ¿administration¿ to reflect the entire process revolving around medication use as well as the physical act of a medication entering an individual¿s body. Other information - Pro re nata (PRN) means on an ¿as needed¿ basis. ¿Special precautions¿ include any specific administration instructions such as: causes drowsiness, take with food, do not take with certain types of other drugs, and so on. The medication record may include the staff person¿s initials (in lieu of the staff person¿s full name) if there is a master key showing each staff person¿s initials, his or her full printed name, and his or her signature/signature stamp, so the individual staff person can be linked to the specific medication record entry. Electronic Medication Records (MRs)¿ Electronic MRs are permissible provided that the system allows only the appropriate person(s) to document that a medication was administered to an individual and that a hard-copy of the MRs for any staff person is available to the Department during any onsite inspection upon request. Inspection Procedures: Licensing staff will review the medication record and the medications kept by the home to ensure all individuals who receive medication administration services have a complete medication record that is kept current. Hard-copy records do not need to be obtained if viewing electronic records is practicable. Primary Benefit: The home¿s staff persons will be able to track all medications an individual receives and to ensure all medications are administered as prescribed.
FCS Response: Loratadine should be pre-populated on the MAR which would help avoid errors.
Immediate Fix: The caregiver already fixed the violation by documenting the Loratadine prescription on the June MAR on 6/6/24. The medication will be pre-populated on future MARs.
Provider¿s Plan of Correction:
1. All Life Sharing Specialists will be trained on the Licensing Inspection Summary and Plan of Correction no later than 6/11/24.
2. Correct the June 2024 MAR that includes Loratadine no later 6/14/2024.
3. All Primary Caregivers will be trained on agency policy, 6500.136 and the applicable 6400 RCG guidance no later than 7/12/24.
4. All homes that were not already inspected by ODP will be checked for compliance with 6500.136 no later than 7/12/24.
5. Copies of all completed paperwork will be sent to ODP no later than 7/15/24.
6. Anthony Fisher, Program Director, will verify that all steps of the Plan of Correction are finalized.
Attachments:
1. Corrected June 2024 MAR (Attachment 4)
2. Training Summary Form for all program staff and the primary caregivers. (Attachment 5)
3. Program check for compliance with 6500.136 (Attachment 6) |
07/15/2024
| Implemented |
| 6500.136(a)(5) | Individual #1 is prescribed Loratadine 10 mg tablets (more commonly known as Claritin). The strength of the medication is not recorded on Individual #1's Medication Administration Record for June 2024. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | Clarification from the 6400 Regulatory Compliance Guide:
Discussion: Proper medication record use is critical, as it: ¿ Creates a record of proper medication administration, ¿ Allows physicians and emergency personnel to know when a medication was last administered; and ¿ Creates a system to account for medications, especially controlled substances. What medications must be recorded on the medication record? ¿ Prescription medications ¿ Over the counter (OTC) medications ¿ Vitamins ¿ Complementary and alternative medications (CAM) ¿ PRN (Pro re nata) medications What medications are not required to be recorded on the medication record? ¿ Nutritional supplements ¿ Special diets PRN medications must be entered into the medication record so that it is available immediately should it be needed. A medication record should always reflect all prescribed medications. Examples of CAM include acupuncture, herbal supplements, and cannabidiol products that contain less than 0.3 percent THC. It is very important that CAM be recorded on the medication record, as these products may have side effects when used with prescribed medications. Aromatherapy is not considered to be CAM and does not need to be recorded on the MR. Nutritional supplements (nutrition shakes, protein powders, etc.) and special diets do not need to be recorded on the medication record, but the home must be aware of and provide nutritional supplements and special diets if ordered by a physician. It is recommended that any nutritional supplement or specific diet recommendation that requires the counting or calories, carbs, fluid ounces, and related information be recorded in the individual¿s assessment. Remember, homes are responsible for ensuring that individuals may take OTC medications without causing allergic reactions or impacting prescription medications prescribed to the individual. What administration information must be recorded on the medication record? If several pills are packaged together in one blister pack and administered together at the same time, information for each pill in the blister must be listed individually on the medication record; the reason for this relates to individuals¿ right to refuse medications. If a person refuses to take a pill or if one or more of the pills in the blister is not administered, the home must have a means of documenting the refusal. The administration of a medication by a source outside of the home (such as a monthly scheduled injection in a physician¿s office or medication administered while visiting family) should not be documented on the medication record for the home. Only medication given by staff members of the home are to be documented on the medication record. However, any documentation given to the individual as a result of receiving administration of a medication by a source outside of the home (such as invoices, doctor¿s notes; etc.) should be kept in the individual¿s record for reference purposes. Diagnosis must be included because the same medications may be used to treat different conditions. If there is a specific time of administration listed on the medications record, such as 8:00 AM and 8:00 PM, the actual clock time of each administration is not required to be recorded. The record can simply include staff initials. This means the medication was given within 60 minutes plus or minus the specified time. If the medication record does not list a clock time (such as am, pm, at breakfast, after lunch) the exact time of administration must be recorded. The generic use of the word ¿administered¿ may contribute to a potential misunderstanding. The medication administration course uses the word ¿administration¿ to reflect the entire process revolving around medication use as well as the physical act of a medication entering an individual¿s body. Other information - Pro re nata (PRN) means on an ¿as needed¿ basis. ¿Special precautions¿ include any specific administration instructions such as: causes drowsiness, take with food, do not take with certain types of other drugs, and so on. The medication record may include the staff person¿s initials (in lieu of the staff person¿s full name) if there is a master key showing each staff person¿s initials, his or her full printed name, and his or her signature/signature stamp, so the individual staff person can be linked to the specific medication record entry. Electronic Medication Records (MRs)¿ Electronic MRs are permissible provided that the system allows only the appropriate person(s) to document that a medication was administered to an individual and that a hard-copy of the MRs for any staff person is available to the Department during any onsite inspection upon request. Inspection Procedures: Licensing staff will review the medication record and the medications kept by the home to ensure all individuals who receive medication administration services have a complete medication record that is kept current. Hard-copy records do not need to be obtained if viewing electronic records is practicable. Primary Benefit: The home¿s staff persons will be able to track all medications an individual receives and to ensure all medications are administered as prescribed.
FCS Response: Loratadine should be pre-populated on the MAR which would help avoid errors.
Immediate Fix: The caregiver already fixed the violation by documenting the Loratadine prescription on the June MAR on 6/6/24. The medication will be pre-populated on future MARs.
Provider¿s Plan of Correction:
1. All Life Sharing Specialists will be trained on the Licensing Inspection Summary and Plan of Correction no later than 6/11/24.
2. Correct the June 2024 MAR that includes Loratadine no later 6/14/2024.
3. All Primary Caregivers will be trained on agency policy, 6500.136 and the applicable 6400 RCG guidance no later than 7/12/24.
4. All homes that were not already inspected by ODP will be checked for compliance with 6500.136 no later than 7/12/24.
5. Copies of all completed paperwork will be sent to ODP no later than 7/15/24.
6. Anthony Fisher, Program Director, will verify that all steps of the Plan of Correction are finalized.
Attachments:
1. Corrected June 2024 MAR (Attachment 4)
2. Training Summary Form for all program staff and the primary caregivers. (Attachment 5)
3. Program check for compliance with 6500.136 (Attachment 6) |
07/15/2024
| Implemented |
| 6500.136(a)(6) | Individual #1 is prescribed Loratadine 10 mg tablets (more commonly known as Claritin). The dosage form of the medication is not recorded on Individual #1's Medication Administration Record for June 2024. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | Clarification from the 6400 Regulatory Compliance Guide:
Discussion: Proper medication record use is critical, as it: ¿ Creates a record of proper medication administration, ¿ Allows physicians and emergency personnel to know when a medication was last administered; and ¿ Creates a system to account for medications, especially controlled substances. What medications must be recorded on the medication record? ¿ Prescription medications ¿ Over the counter (OTC) medications ¿ Vitamins ¿ Complementary and alternative medications (CAM) ¿ PRN (Pro re nata) medications What medications are not required to be recorded on the medication record? ¿ Nutritional supplements ¿ Special diets PRN medications must be entered into the medication record so that it is available immediately should it be needed. A medication record should always reflect all prescribed medications. Examples of CAM include acupuncture, herbal supplements, and cannabidiol products that contain less than 0.3 percent THC. It is very important that CAM be recorded on the medication record, as these products may have side effects when used with prescribed medications. Aromatherapy is not considered to be CAM and does not need to be recorded on the MR. Nutritional supplements (nutrition shakes, protein powders, etc.) and special diets do not need to be recorded on the medication record, but the home must be aware of and provide nutritional supplements and special diets if ordered by a physician. It is recommended that any nutritional supplement or specific diet recommendation that requires the counting or calories, carbs, fluid ounces, and related information be recorded in the individual¿s assessment. Remember, homes are responsible for ensuring that individuals may take OTC medications without causing allergic reactions or impacting prescription medications prescribed to the individual. What administration information must be recorded on the medication record? If several pills are packaged together in one blister pack and administered together at the same time, information for each pill in the blister must be listed individually on the medication record; the reason for this relates to individuals¿ right to refuse medications. If a person refuses to take a pill or if one or more of the pills in the blister is not administered, the home must have a means of documenting the refusal. The administration of a medication by a source outside of the home (such as a monthly scheduled injection in a physician¿s office or medication administered while visiting family) should not be documented on the medication record for the home. Only medication given by staff members of the home are to be documented on the medication record. However, any documentation given to the individual as a result of receiving administration of a medication by a source outside of the home (such as invoices, doctor¿s notes; etc.) should be kept in the individual¿s record for reference purposes. Diagnosis must be included because the same medications may be used to treat different conditions. If there is a specific time of administration listed on the medications record, such as 8:00 AM and 8:00 PM, the actual clock time of each administration is not required to be recorded. The record can simply include staff initials. This means the medication was given within 60 minutes plus or minus the specified time. If the medication record does not list a clock time (such as am, pm, at breakfast, after lunch) the exact time of administration must be recorded. The generic use of the word ¿administered¿ may contribute to a potential misunderstanding. The medication administration course uses the word ¿administration¿ to reflect the entire process revolving around medication use as well as the physical act of a medication entering an individual¿s body. Other information - Pro re nata (PRN) means on an ¿as needed¿ basis. ¿Special precautions¿ include any specific administration instructions such as: causes drowsiness, take with food, do not take with certain types of other drugs, and so on. The medication record may include the staff person¿s initials (in lieu of the staff person¿s full name) if there is a master key showing each staff person¿s initials, his or her full printed name, and his or her signature/signature stamp, so the individual staff person can be linked to the specific medication record entry. Electronic Medication Records (MRs)¿ Electronic MRs are permissible provided that the system allows only the appropriate person(s) to document that a medication was administered to an individual and that a hard-copy of the MRs for any staff person is available to the Department during any onsite inspection upon request. Inspection Procedures: Licensing staff will review the medication record and the medications kept by the home to ensure all individuals who receive medication administration services have a complete medication record that is kept current. Hard-copy records do not need to be obtained if viewing electronic records is practicable. Primary Benefit: The home¿s staff persons will be able to track all medications an individual receives and to ensure all medications are administered as prescribed.
FCS Response: Loratadine should be pre-populated on the MAR which would help avoid errors.
Immediate Fix: The caregiver already fixed the violation by documenting the Loratadine prescription on the June MAR on 6/6/24. The medication will be pre-populated on future MARs.
Provider¿s Plan of Correction:
1. All Life Sharing Specialists will be trained on the Licensing Inspection Summary and Plan of Correction no later than 6/11/24.
2. Correct the June 2024 MAR that includes Loratadine no later 6/14/2024.
3. All Primary Caregivers will be trained on agency policy, 6500.136 and the applicable 6400 RCG guidance no later than 7/12/24.
4. All homes that were not already inspected by ODP will be checked for compliance with 6500.136 no later than 7/12/24.
5. Copies of all completed paperwork will be sent to ODP no later than 7/15/24.
6. Anthony Fisher, Program Director, will verify that all steps of the Plan of Correction are finalized.
Attachments:
1. Corrected June 2024 MAR (Attachment 4)
2. Training Summary Form for all program staff and the primary caregivers. (Attachment 5)
3. Program check for compliance with 6500.136 (Attachment 6) |
07/15/2024
| Implemented |
| 6500.136(a)(7) | Individual #1 is prescribed Loratadine 10 mg tablets (more commonly known as Claritin) The dose of the medication is not recorded on Individual #1's Medication Administration Record for June 2024. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | Clarification from the 6400 Regulatory Compliance Guide:
Discussion: Proper medication record use is critical, as it: ¿ Creates a record of proper medication administration, ¿ Allows physicians and emergency personnel to know when a medication was last administered; and ¿ Creates a system to account for medications, especially controlled substances. What medications must be recorded on the medication record? ¿ Prescription medications ¿ Over the counter (OTC) medications ¿ Vitamins ¿ Complementary and alternative medications (CAM) ¿ PRN (Pro re nata) medications What medications are not required to be recorded on the medication record? ¿ Nutritional supplements ¿ Special diets PRN medications must be entered into the medication record so that it is available immediately should it be needed. A medication record should always reflect all prescribed medications. Examples of CAM include acupuncture, herbal supplements, and cannabidiol products that contain less than 0.3 percent THC. It is very important that CAM be recorded on the medication record, as these products may have side effects when used with prescribed medications. Aromatherapy is not considered to be CAM and does not need to be recorded on the MR. Nutritional supplements (nutrition shakes, protein powders, etc.) and special diets do not need to be recorded on the medication record, but the home must be aware of and provide nutritional supplements and special diets if ordered by a physician. It is recommended that any nutritional supplement or specific diet recommendation that requires the counting or calories, carbs, fluid ounces, and related information be recorded in the individual¿s assessment. Remember, homes are responsible for ensuring that individuals may take OTC medications without causing allergic reactions or impacting prescription medications prescribed to the individual. What administration information must be recorded on the medication record? If several pills are packaged together in one blister pack and administered together at the same time, information for each pill in the blister must be listed individually on the medication record; the reason for this relates to individuals¿ right to refuse medications. If a person refuses to take a pill or if one or more of the pills in the blister is not administered, the home must have a means of documenting the refusal. The administration of a medication by a source outside of the home (such as a monthly scheduled injection in a physician¿s office or medication administered while visiting family) should not be documented on the medication record for the home. Only medication given by staff members of the home are to be documented on the medication record. However, any documentation given to the individual as a result of receiving administration of a medication by a source outside of the home (such as invoices, doctor¿s notes; etc.) should be kept in the individual¿s record for reference purposes. Diagnosis must be included because the same medications may be used to treat different conditions. If there is a specific time of administration listed on the medications record, such as 8:00 AM and 8:00 PM, the actual clock time of each administration is not required to be recorded. The record can simply include staff initials. This means the medication was given within 60 minutes plus or minus the specified time. If the medication record does not list a clock time (such as am, pm, at breakfast, after lunch) the exact time of administration must be recorded. The generic use of the word ¿administered¿ may contribute to a potential misunderstanding. The medication administration course uses the word ¿administration¿ to reflect the entire process revolving around medication use as well as the physical act of a medication entering an individual¿s body. Other information - Pro re nata (PRN) means on an ¿as needed¿ basis. ¿Special precautions¿ include any specific administration instructions such as: causes drowsiness, take with food, do not take with certain types of other drugs, and so on. The medication record may include the staff person¿s initials (in lieu of the staff person¿s full name) if there is a master key showing each staff person¿s initials, his or her full printed name, and his or her signature/signature stamp, so the individual staff person can be linked to the specific medication record entry. Electronic Medication Records (MRs)¿ Electronic MRs are permissible provided that the system allows only the appropriate person(s) to document that a medication was administered to an individual and that a hard-copy of the MRs for any staff person is available to the Department during any onsite inspection upon request. Inspection Procedures: Licensing staff will review the medication record and the medications kept by the home to ensure all individuals who receive medication administration services have a complete medication record that is kept current. Hard-copy records do not need to be obtained if viewing electronic records is practicable. Primary Benefit: The home¿s staff persons will be able to track all medications an individual receives and to ensure all medications are administered as prescribed.
FCS Response: Loratadine should be pre-populated on the MAR which would help avoid errors.
Immediate Fix: The caregiver already fixed the violation by documenting the Loratadine prescription on the June MAR on 6/6/24. The medication will be pre-populated on future MARs.
Provider¿s Plan of Correction:
1. All Life Sharing Specialists will be trained on the Licensing Inspection Summary and Plan of Correction no later than 6/11/24.
2. Correct the June 2024 MAR that includes Loratadine no later 6/14/2024.
3. All Primary Caregivers will be trained on agency policy, 6500.136 and the applicable 6400 RCG guidance no later than 7/12/24.
4. All homes that were not already inspected by ODP will be checked for compliance with 6500.136 no later than 7/12/24.
5. Copies of all completed paperwork will be sent to ODP no later than 7/15/24.
6. Anthony Fisher, Program Director, will verify that all steps of the Plan of Correction are finalized.
Attachments:
1. Corrected June 2024 MAR (Attachment 4)
2. Training Summary Form for all program staff and the primary caregivers. (Attachment 5)
3. Program check for compliance with 6500.136 (Attachment 6) |
07/15/2024
| Implemented |
| 6500.136(a)(8) | Individual #1 is prescribed Loratadine 10 mg tablets (more commonly known as Claritin). The route of medication administration is not recorded on Individual #1's Medication Administration Record for June 2024. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | Clarification from the 6400 Regulatory Compliance Guide:
Discussion: Proper medication record use is critical, as it: ¿ Creates a record of proper medication administration, ¿ Allows physicians and emergency personnel to know when a medication was last administered; and ¿ Creates a system to account for medications, especially controlled substances. What medications must be recorded on the medication record? ¿ Prescription medications ¿ Over the counter (OTC) medications ¿ Vitamins ¿ Complementary and alternative medications (CAM) ¿ PRN (Pro re nata) medications What medications are not required to be recorded on the medication record? ¿ Nutritional supplements ¿ Special diets PRN medications must be entered into the medication record so that it is available immediately should it be needed. A medication record should always reflect all prescribed medications. Examples of CAM include acupuncture, herbal supplements, and cannabidiol products that contain less than 0.3 percent THC. It is very important that CAM be recorded on the medication record, as these products may have side effects when used with prescribed medications. Aromatherapy is not considered to be CAM and does not need to be recorded on the MR. Nutritional supplements (nutrition shakes, protein powders, etc.) and special diets do not need to be recorded on the medication record, but the home must be aware of and provide nutritional supplements and special diets if ordered by a physician. It is recommended that any nutritional supplement or specific diet recommendation that requires the counting or calories, carbs, fluid ounces, and related information be recorded in the individual¿s assessment. Remember, homes are responsible for ensuring that individuals may take OTC medications without causing allergic reactions or impacting prescription medications prescribed to the individual. What administration information must be recorded on the medication record? If several pills are packaged together in one blister pack and administered together at the same time, information for each pill in the blister must be listed individually on the medication record; the reason for this relates to individuals¿ right to refuse medications. If a person refuses to take a pill or if one or more of the pills in the blister is not administered, the home must have a means of documenting the refusal. The administration of a medication by a source outside of the home (such as a monthly scheduled injection in a physician¿s office or medication administered while visiting family) should not be documented on the medication record for the home. Only medication given by staff members of the home are to be documented on the medication record. However, any documentation given to the individual as a result of receiving administration of a medication by a source outside of the home (such as invoices, doctor¿s notes; etc.) should be kept in the individual¿s record for reference purposes. Diagnosis must be included because the same medications may be used to treat different conditions. If there is a specific time of administration listed on the medications record, such as 8:00 AM and 8:00 PM, the actual clock time of each administration is not required to be recorded. The record can simply include staff initials. This means the medication was given within 60 minutes plus or minus the specified time. If the medication record does not list a clock time (such as am, pm, at breakfast, after lunch) the exact time of administration must be recorded. The generic use of the word ¿administered¿ may contribute to a potential misunderstanding. The medication administration course uses the word ¿administration¿ to reflect the entire process revolving around medication use as well as the physical act of a medication entering an individual¿s body. Other information - Pro re nata (PRN) means on an ¿as needed¿ basis. ¿Special precautions¿ include any specific administration instructions such as: causes drowsiness, take with food, do not take with certain types of other drugs, and so on. The medication record may include the staff person¿s initials (in lieu of the staff person¿s full name) if there is a master key showing each staff person¿s initials, his or her full printed name, and his or her signature/signature stamp, so the individual staff person can be linked to the specific medication record entry. Electronic Medication Records (MRs)¿ Electronic MRs are permissible provided that the system allows only the appropriate person(s) to document that a medication was administered to an individual and that a hard-copy of the MRs for any staff person is available to the Department during any onsite inspection upon request. Inspection Procedures: Licensing staff will review the medication record and the medications kept by the home to ensure all individuals who receive medication administration services have a complete medication record that is kept current. Hard-copy records do not need to be obtained if viewing electronic records is practicable. Primary Benefit: The home¿s staff persons will be able to track all medications an individual receives and to ensure all medications are administered as prescribed.
FCS Response: Loratadine should be pre-populated on the MAR which would help avoid errors.
Immediate Fix: The caregiver already fixed the violation by documenting the Loratadine prescription on the June MAR on 6/6/24. The medication will be pre-populated on future MARs.
Provider¿s Plan of Correction:
1. All Life Sharing Specialists will be trained on the Licensing Inspection Summary and Plan of Correction no later than 6/11/24.
2. Correct the June 2024 MAR that includes Loratadine no later 6/14/2024.
3. All Primary Caregivers will be trained on agency policy, 6500.136 and the applicable 6400 RCG guidance no later than 7/12/24.
4. All homes that were not already inspected by ODP will be checked for compliance with 6500.136 no later than 7/12/24.
5. Copies of all completed paperwork will be sent to ODP no later than 7/15/24.
6. Anthony Fisher, Program Director, will verify that all steps of the Plan of Correction are finalized.
Attachments:
1. Corrected June 2024 MAR (Attachment 4)
2. Training Summary Form for all program staff and the primary caregivers. (Attachment 5)
3. Program check for compliance with 6500.136 (Attachment 6) |
07/15/2024
| Implemented |
| 6500.136(a)(9) | Individual #1 is prescribed Loratadine 10 mg tablets (more commonly known as Claritin). The frequency of medication administration is not recorded on Individual #1's Medication Administration Record for June 2024. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | Clarification from the 6400 Regulatory Compliance Guide:
Discussion: Proper medication record use is critical, as it: ¿ Creates a record of proper medication administration, ¿ Allows physicians and emergency personnel to know when a medication was last administered; and ¿ Creates a system to account for medications, especially controlled substances. What medications must be recorded on the medication record? ¿ Prescription medications ¿ Over the counter (OTC) medications ¿ Vitamins ¿ Complementary and alternative medications (CAM) ¿ PRN (Pro re nata) medications What medications are not required to be recorded on the medication record? ¿ Nutritional supplements ¿ Special diets PRN medications must be entered into the medication record so that it is available immediately should it be needed. A medication record should always reflect all prescribed medications. Examples of CAM include acupuncture, herbal supplements, and cannabidiol products that contain less than 0.3 percent THC. It is very important that CAM be recorded on the medication record, as these products may have side effects when used with prescribed medications. Aromatherapy is not considered to be CAM and does not need to be recorded on the MR. Nutritional supplements (nutrition shakes, protein powders, etc.) and special diets do not need to be recorded on the medication record, but the home must be aware of and provide nutritional supplements and special diets if ordered by a physician. It is recommended that any nutritional supplement or specific diet recommendation that requires the counting or calories, carbs, fluid ounces, and related information be recorded in the individual¿s assessment. Remember, homes are responsible for ensuring that individuals may take OTC medications without causing allergic reactions or impacting prescription medications prescribed to the individual. What administration information must be recorded on the medication record? If several pills are packaged together in one blister pack and administered together at the same time, information for each pill in the blister must be listed individually on the medication record; the reason for this relates to individuals¿ right to refuse medications. If a person refuses to take a pill or if one or more of the pills in the blister is not administered, the home must have a means of documenting the refusal. The administration of a medication by a source outside of the home (such as a monthly scheduled injection in a physician¿s office or medication administered while visiting family) should not be documented on the medication record for the home. Only medication given by staff members of the home are to be documented on the medication record. However, any documentation given to the individual as a result of receiving administration of a medication by a source outside of the home (such as invoices, doctor¿s notes; etc.) should be kept in the individual¿s record for reference purposes. Diagnosis must be included because the same medications may be used to treat different conditions. If there is a specific time of administration listed on the medications record, such as 8:00 AM and 8:00 PM, the actual clock time of each administration is not required to be recorded. The record can simply include staff initials. This means the medication was given within 60 minutes plus or minus the specified time. If the medication record does not list a clock time (such as am, pm, at breakfast, after lunch) the exact time of administration must be recorded. The generic use of the word ¿administered¿ may contribute to a potential misunderstanding. The medication administration course uses the word ¿administration¿ to reflect the entire process revolving around medication use as well as the physical act of a medication entering an individual¿s body. Other information - Pro re nata (PRN) means on an ¿as needed¿ basis. ¿Special precautions¿ include any specific administration instructions such as: causes drowsiness, take with food, do not take with certain types of other drugs, and so on. The medication record may include the staff person¿s initials (in lieu of the staff person¿s full name) if there is a master key showing each staff person¿s initials, his or her full printed name, and his or her signature/signature stamp, so the individual staff person can be linked to the specific medication record entry. Electronic Medication Records (MRs)¿ Electronic MRs are permissible provided that the system allows only the appropriate person(s) to document that a medication was administered to an individual and that a hard-copy of the MRs for any staff person is available to the Department during any onsite inspection upon request. Inspection Procedures: Licensing staff will review the medication record and the medications kept by the home to ensure all individuals who receive medication administration services have a complete medication record that is kept current. Hard-copy records do not need to be obtained if viewing electronic records is practicable. Primary Benefit: The home¿s staff persons will be able to track all medications an individual receives and to ensure all medications are administered as prescribed.
FCS Response: Loratadine should be pre-populated on the MAR which would help avoid errors.
Immediate Fix: The caregiver already fixed the violation by documenting the Loratadine prescription on the June MAR on 6/6/24. The medication will be pre-populated on future MARs.
Provider¿s Plan of Correction:
1. All Life Sharing Specialists will be trained on the Licensing Inspection Summary and Plan of Correction no later than 6/11/24.
2. Correct the June 2024 MAR that includes Loratadine no later 6/14/2024.
3. All Primary Caregivers will be trained on agency policy, 6500.136 and the applicable 6400 RCG guidance no later than 7/12/24.
4. All homes that were not already inspected by ODP will be checked for compliance with 6500.136 no later than 7/12/24.
5. Copies of all completed paperwork will be sent to ODP no later than 7/15/24.
6. Anthony Fisher, Program Director, will verify that all steps of the Plan of Correction are finalized.
Attachments:
1. Corrected June 2024 MAR (Attachment 4)
2. Training Summary Form for all program staff and the primary caregivers. (Attachment 5)
3. Program check for compliance with 6500.136 (Attachment 6) |
07/15/2024
| Implemented |
| 6500.136(a)(10) | Individual #1 is prescribed Loratadine 10 mg tablets (more commonly known as Claritin). The medication administration times are not recorded on Individual #1's Medication Administration Record for June 2024. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | Clarification from the 6400 Regulatory Compliance Guide:
Discussion: Proper medication record use is critical, as it: ¿ Creates a record of proper medication administration, ¿ Allows physicians and emergency personnel to know when a medication was last administered; and ¿ Creates a system to account for medications, especially controlled substances. What medications must be recorded on the medication record? ¿ Prescription medications ¿ Over the counter (OTC) medications ¿ Vitamins ¿ Complementary and alternative medications (CAM) ¿ PRN (Pro re nata) medications What medications are not required to be recorded on the medication record? ¿ Nutritional supplements ¿ Special diets PRN medications must be entered into the medication record so that it is available immediately should it be needed. A medication record should always reflect all prescribed medications. Examples of CAM include acupuncture, herbal supplements, and cannabidiol products that contain less than 0.3 percent THC. It is very important that CAM be recorded on the medication record, as these products may have side effects when used with prescribed medications. Aromatherapy is not considered to be CAM and does not need to be recorded on the MR. Nutritional supplements (nutrition shakes, protein powders, etc.) and special diets do not need to be recorded on the medication record, but the home must be aware of and provide nutritional supplements and special diets if ordered by a physician. It is recommended that any nutritional supplement or specific diet recommendation that requires the counting or calories, carbs, fluid ounces, and related information be recorded in the individual¿s assessment. Remember, homes are responsible for ensuring that individuals may take OTC medications without causing allergic reactions or impacting prescription medications prescribed to the individual. What administration information must be recorded on the medication record? If several pills are packaged together in one blister pack and administered together at the same time, information for each pill in the blister must be listed individually on the medication record; the reason for this relates to individuals¿ right to refuse medications. If a person refuses to take a pill or if one or more of the pills in the blister is not administered, the home must have a means of documenting the refusal. The administration of a medication by a source outside of the home (such as a monthly scheduled injection in a physician¿s office or medication administered while visiting family) should not be documented on the medication record for the home. Only medication given by staff members of the home are to be documented on the medication record. However, any documentation given to the individual as a result of receiving administration of a medication by a source outside of the home (such as invoices, doctor¿s notes; etc.) should be kept in the individual¿s record for reference purposes. Diagnosis must be included because the same medications may be used to treat different conditions. If there is a specific time of administration listed on the medications record, such as 8:00 AM and 8:00 PM, the actual clock time of each administration is not required to be recorded. The record can simply include staff initials. This means the medication was given within 60 minutes plus or minus the specified time. If the medication record does not list a clock time (such as am, pm, at breakfast, after lunch) the exact time of administration must be recorded. The generic use of the word ¿administered¿ may contribute to a potential misunderstanding. The medication administration course uses the word ¿administration¿ to reflect the entire process revolving around medication use as well as the physical act of a medication entering an individual¿s body. Other information - Pro re nata (PRN) means on an ¿as needed¿ basis. ¿Special precautions¿ include any specific administration instructions such as: causes drowsiness, take with food, do not take with certain types of other drugs, and so on. The medication record may include the staff person¿s initials (in lieu of the staff person¿s full name) if there is a master key showing each staff person¿s initials, his or her full printed name, and his or her signature/signature stamp, so the individual staff person can be linked to the specific medication record entry. Electronic Medication Records (MRs)¿ Electronic MRs are permissible provided that the system allows only the appropriate person(s) to document that a medication was administered to an individual and that a hard-copy of the MRs for any staff person is available to the Department during any onsite inspection upon request. Inspection Procedures: Licensing staff will review the medication record and the medications kept by the home to ensure all individuals who receive medication administration services have a complete medication record that is kept current. Hard-copy records do not need to be obtained if viewing electronic records is practicable. Primary Benefit: The home¿s staff persons will be able to track all medications an individual receives and to ensure all medications are administered as prescribed.
FCS Response: Loratadine should be pre-populated on the MAR which would help avoid errors.
Immediate Fix: The caregiver already fixed the violation by documenting the Loratadine prescription on the June MAR on 6/6/24. The medication will be pre-populated on future MARs.
Provider¿s Plan of Correction:
1. All Life Sharing Specialists will be trained on the Licensing Inspection Summary and Plan of Correction no later than 6/11/24.
2. Correct the June 2024 MAR that includes Loratadine no later 6/14/2024.
3. All Primary Caregivers will be trained on agency policy, 6500.136 and the applicable 6400 RCG guidance no later than 7/12/24.
4. All homes that were not already inspected by ODP will be checked for compliance with 6500.136 no later than 7/12/24.
5. Copies of all completed paperwork will be sent to ODP no later than 7/15/24.
6. Anthony Fisher, Program Director, will verify that all steps of the Plan of Correction are finalized.
Attachments:
1. Corrected June 2024 MAR (Attachment 4)
2. Training Summary Form for all program staff and the primary caregivers. (Attachment 5)
3. Program check for compliance with 6500.136 (Attachment 6) |
07/15/2024
| Implemented |
| 6500.136(a)(11) | Individual #1 is prescribed Loratadine 10 mg tablets (more commonly known as Claritin). The diagnosis or purpose of the medication, including pro re nata is not recorded on Individual #1's Medication Administration Record for June 2024. | 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. | Clarification from the 6400 Regulatory Compliance Guide:
Discussion: Proper medication record use is critical, as it: ¿ Creates a record of proper medication administration, ¿ Allows physicians and emergency personnel to know when a medication was last administered; and ¿ Creates a system to account for medications, especially controlled substances. What medications must be recorded on the medication record? ¿ Prescription medications ¿ Over the counter (OTC) medications ¿ Vitamins ¿ Complementary and alternative medications (CAM) ¿ PRN (Pro re nata) medications What medications are not required to be recorded on the medication record? ¿ Nutritional supplements ¿ Special diets PRN medications must be entered into the medication record so that it is available immediately should it be needed. A medication record should always reflect all prescribed medications. Examples of CAM include acupuncture, herbal supplements, and cannabidiol products that contain less than 0.3 percent THC. It is very important that CAM be recorded on the medication record, as these products may have side effects when used with prescribed medications. Aromatherapy is not considered to be CAM and does not need to be recorded on the MR. Nutritional supplements (nutrition shakes, protein powders, etc.) and special diets do not need to be recorded on the medication record, but the home must be aware of and provide nutritional supplements and special diets if ordered by a physician. It is recommended that any nutritional supplement or specific diet recommendation that requires the counting or calories, carbs, fluid ounces, and related information be recorded in the individual¿s assessment. Remember, homes are responsible for ensuring that individuals may take OTC medications without causing allergic reactions or impacting prescription medications prescribed to the individual. What administration information must be recorded on the medication record? If several pills are packaged together in one blister pack and administered together at the same time, information for each pill in the blister must be listed individually on the medication record; the reason for this relates to individuals¿ right to refuse medications. If a person refuses to take a pill or if one or more of the pills in the blister is not administered, the home must have a means of documenting the refusal. The administration of a medication by a source outside of the home (such as a monthly scheduled injection in a physician¿s office or medication administered while visiting family) should not be documented on the medication record for the home. Only medication given by staff members of the home are to be documented on the medication record. However, any documentation given to the individual as a result of receiving administration of a medication by a source outside of the home (such as invoices, doctor¿s notes; etc.) should be kept in the individual¿s record for reference purposes. Diagnosis must be included because the same medications may be used to treat different conditions. If there is a specific time of administration listed on the medications record, such as 8:00 AM and 8:00 PM, the actual clock time of each administration is not required to be recorded. The record can simply include staff initials. This means the medication was given within 60 minutes plus or minus the specified time. If the medication record does not list a clock time (such as am, pm, at breakfast, after lunch) the exact time of administration must be recorded. The generic use of the word ¿administered¿ may contribute to a potential misunderstanding. The medication administration course uses the word ¿administration¿ to reflect the entire process revolving around medication use as well as the physical act of a medication entering an individual¿s body. Other information - Pro re nata (PRN) means on an ¿as needed¿ basis. ¿Special precautions¿ include any specific administration instructions such as: causes drowsiness, take with food, do not take with certain types of other drugs, and so on. The medication record may include the staff person¿s initials (in lieu of the staff person¿s full name) if there is a master key showing each staff person¿s initials, his or her full printed name, and his or her signature/signature stamp, so the individual staff person can be linked to the specific medication record entry. Electronic Medication Records (MRs)¿ Electronic MRs are permissible provided that the system allows only the appropriate person(s) to document that a medication was administered to an individual and that a hard-copy of the MRs for any staff person is available to the Department during any onsite inspection upon request. Inspection Procedures: Licensing staff will review the medication record and the medications kept by the home to ensure all individuals who receive medication administration services have a complete medication record that is kept current. Hard-copy records do not need to be obtained if viewing electronic records is practicable. Primary Benefit: The home¿s staff persons will be able to track all medications an individual receives and to ensure all medications are administered as prescribed.
FCS Response: Loratadine should be pre-populated on the MAR which would help avoid errors.
Immediate Fix: The caregiver already fixed the violation by documenting the Loratadine prescription on the June MAR on 6/6/24. The medication will be pre-populated on future MARs.
Provider¿s Plan of Correction:
1. All Life Sharing Specialists will be trained on the Licensing Inspection Summary and Plan of Correction no later than 6/11/24.
2. Correct the June 2024 MAR that includes Loratadine no later 6/14/2024.
3. All Primary Caregivers will be trained on agency policy, 6500.136 and the applicable 6400 RCG guidance no later than 7/12/24.
4. All homes that were not already inspected by ODP will be checked for compliance with 6500.136 no later than 7/12/24.
5. Copies of all completed paperwork will be sent to ODP no later than 7/15/24.
6. Anthony Fisher, Program Director, will verify that all steps of the Plan of Correction are finalized.
Attachments:
1. Corrected June 2024 MAR (Attachment 4)
2. Training Summary Form for all program staff and the primary caregivers. (Attachment 5)
3. Program check for compliance with 6500.136 (Attachment 6) |
07/15/2024
| Implemented |
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