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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.144 | Individual #1 was discharged from an extended hospitalization on 12/21/20. The 12/21/20 discharge orders indicate that Individual #1 is diagnosed with an "unspecified protein-calorie malnutrition." The discharge orders stated that treating Individual #1's malnutrition may improve PICA symptoms. Individual #1 was receiving oral nutritional supplements (ONS, for example: Ensure) The discharging physician recommendes that "if patient continues to have intakes at 75 -- 100% of meals and weights are stable, it may be acceptable that patient not continue ONS. However, for best nutritional assessment, weekly weight trending and nutritional composition of meals is best reviewed." Valley Community Services has completed regular weight checks, however, they have not been tracking the completion of Individual #1's meals, nor have they had a review completed of the nutritional composition of Individual #1's meals. Valley Community Service discontinued the use of Oral Nutritional Supplements upon Individual #1's discharge with no further physician consultation.
Additionally, at the time of the 12/21/20 discharge, a dysphagia level 2 (mechanical soft) diet with thin liquids was ordered for Individual #1. At the 5/4/22 inspection, staff person #1 was witnessed preparing a grilled cheese and tomato soup for Individual #1. After both foods were cooked, which would have both fallen under the "mechanical soft" designation, staff person #1 then pureed both foods, along with saltine crackers, and served the meal as one pudding-like bowl of food. Staff person #1 also indicated that the day before the 5/4/22 inspection, Individual #1 ate a cheeseburger that was prepared the same way.
Individual #1 had an appointment with their PCP on 4/14/21 as a follow up to an illness and weight loss that occurred in 3/2022. The PCP ordered that Individual #1 needed to have their oxygen levels observed, and that the PCP was to be contacted if oxygen levels decreased to less than 89%. As of 5/3/22, Individual #1's oxygen level monitoring had not been completed. Valley Community Services confirmed that this physician's orders were not implemented. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Valley Community Services utilizes a menu book created by a licensed dietitian. New recipes and menu requests are sent to the licensed dietitian to approve and/or modify the option to ensure a well-balanced nutritional diet. Each CLA creates a weekly menu with input from the individuals. However, all individuals have the right to unfettered access to all food in the home. Many use funds to purchase food items that they may consume as they choose. The agency utilizes the caloric count for persons served when required by the physician. Individual #1s meals are now tracked by percentage option found in Therap per physicians order. This data will be tracked weekly by the Program Specialist and available to the primary care physician at each appointment. To ensure accuracy, the comments section will be utilized for the amount of protein consumed. All staff working at CLA have been trained on the use of percentages and comments section by the Quality Assurance Associate on 06/14/2022. The Program Specialists were trained on reviewing the data weekly by the Quality Assurance & Training Associate by 06/14/2022. The outlines and attendance records are attached for review. If any persons served physician requests percentage, the Program Managers have been trained to alert the Quality Assurance department and Operations Director immediately via email. The staff will be immediately trained with a live training prior to working with the individual and implemented. The staff will also be trained at the next scheduled staff meeting by either the Operations Director or the Quality Assurance department.
Agency-wide training with Operations Directors, Program Specialists, Program Managers, and supervisory staff was completed by 06/14/2022 on the utilization of the IDDSI information by the Director of Quality Assurance & Training. This information will be kept in the menu book for reference. Proper meal preparation was reviewed with a question-and-answer session for CLA on 06/14/2022 by Healthcare Director. Valley Community Services has procured the licensed dietician to aid with special diets at CLAs agency wide. She will conduct a training for all Program Managers by 07/30/22 with the IDDSI. She has agreed to review current physician diet orders. She will also help with new individuals admissions by working with the Quality Assurance department on key questions to have answered prior to admission. If/when a CLA needs help with any new dietary issues, the dietitian will be on retainer to review the prescribed diet with the staff. Incoming staff will be trained by the Program Manager or designee on proper preparation with a return demonstration required. This will be documented in the employees training file with Human Resources. This training will include the necessity to reheat any food items that are no longer at the proper temperature. Random monitoring for CLA will be completed by the HealthCare Officer twice a month starting 06/15/2022 and ending 09/15/2022. Any issues will be immediately addressed. The Quality Assurance & Training department and the homes Operations Director will be informed, and a house-wide training will be completed within one week of the incident.
Agency-wide training was completed with the Program Managers and supervisory staff by the Director of Quality Assurance & Training regarding their responsibility to review, document, and scan all instructions presented on a Medical Review form upon return from an appointment. A live training is to be completed with all staff prior to anyone working with the individual. Program Specialists were trained by the Director of Quality Assurance & Training on reviewing all appointment documentation weekly to ensure compliance. The trainings were completed by 06/14/2022. The outline and attendance records are sent for review.
All staff at the CLA have been instructed to complete Pulse Ox for Individual #1 starting 05/04/2022. They have been instructed that any number below 89% must be reported to the Primary Care Physician. This training was completed by the Program Manager on 05/04/2022. Outline and attendance record attached for review. |
06/14/2022
| Implemented |
| 6400.32(c) | Individual #1 is to have 2:1 staffing 24 hours/day, with 1 staff within arm's length at all times, including during sleeping hours, and 1 staff within hearing distance at all times due to Numerous hospitalizations surrounding their PICA behaviors. Staff switch every hour and are to track when they are switching to ensure Individual #1 always remains supervised. Staff were not following Individual #1's supervision protocols on the following dates:
-8/12/21 -- 10am -- 11am -- The chart states "OP." Individual #1's sleep chart indicates they were sleeping from 9:30am to 12:00pm.
-3/2/22 -- 9pm -- 9:15pm -- The chart states Individual #1 was in "line of sight." Individual #1's sleep chart indicates they were awake during this time.
-3/13/22 -- 2am -- 3am -- Both the supervision and sleeping charts are blank for this time.
-4/6/22 -- 11pm -- 12am -- The supervision chart is blank, but the sleep chart indicates Individual #1 was sleeping.
-4/22/22 -- 8:45pm -- 9pm -- The supervision chart is blank, but the sleep chart indicates Individual #1 was awake.
-4/23/22 -- 11:30pm -- 12a -- The supervision chart is blank, but the sleep chart indicates Individual #1 was sleeping.
Failure to provide proper supervision constitutes neglect and could put Individual #1's health and safety in jeopardy. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | An investigation for neglect was started upon receipt of the LIS. All Administrative Review Committee training requirements will be completed upon receipt of the recommendations.
The Gephart CLA staff were retrained on the switching of duties hourly to ensure Individual #1 always remains supervised by the Quality Assurance & Training Associate on 06/14/2022. Upon review of the Therap data, documentation was missing or made in error. All current DSPs have been reassigned Time Tracking in the Relias LMS system. To ensure accurate and up to date data is completed, the Program Managers and supervisory staff will review data daily. Missing data will be addressed with the appropriate staff. Training was completed on 06/14/2022. Outline and attendance records are submitted for review. |
06/14/2022
| Implemented |
| 6400.32(d) | Individual #1 is to be on a level 2 dysphagia mechanical soft diet with thin liquids. This allows for foods with texture, chopped finely. At the 5/4/22 inspection, staff person #1 was witnessed preparing a grilled cheese and tomato soup for Individual #1. After both foods were cooked, which would have both fallen under the "mechanical soft" designation, staff person #1 then pureed both foods, along with saltine crackers, and served the meal as one pudding-like bowl of food. Staff person #1 also indicated that the day before the 5/4/22 inspection, Individual #1 ate a cheeseburger that was prepared the same way. Individual #1's ISP dated 4/7/22 states that, "having something appropriate for [their] mouth keeps [them] calm and happy." Staff person #1 confirmed that Individual #1 enjoys having various textures in their mouth. Preparing Individual #1's food at a pureed consistency, which is lower than what is ordered by the physician, is undignified and disrespectful as it infantilizes Individual #1. | An individual shall be treated with dignity and respect. | Agency-wide training with Operations Directors, Program Specialists, Program Managers, and supervisory staff was completed by 06/14/2022 on the utilization of the IDDSI information by the Director of Quality Assurance & Training. This information will be kept in the menu book for reference. Proper meal preparation was reviewed with a question-and-answer session for CLA on 06/14/2022 by Healthcare Director. Incoming staff will be trained by the Program Manager or designee on proper preparation with a return demonstration required. This will be documented in the employees training file with Human Resources. This training will include the necessity to reheat any food items that are no longer at the proper temperature. Random monitoring for CLA will be completed by the HealthCare Officer twice a month starting 06/15/2022 and ending 09/15/2022. Any issues will be immediately addressed. The Quality Assurance & Training department and the homes Operations Director will be informed, and a house-wide training will be completed within one week of the incident. |
09/15/2022
| Implemented |
| 6400.51(b)(5) | Individual #1 returned to the home on 12/21/20 after an extended hospitalization. At the time of the individual's return, multiple plans and protocols were put into place to ensure Individual #1's health and safety.
-A staff support plan was written and implemented in 11/2020.
-An environmental sweep plan was written and implemented in 11/2020.
-A medication refusal and medical appointment refusal plan was written and implemented on 12/21/20 and updated on 12/7/21.
-A PICA plan was written and implemented on 12/21/20.
-A dental hygiene plan was written and implemented on 12/21/20 and updated on 12/7/21.
-A choking prevention plan was written and implemented on 12/7/20 and updated on 12/7/21.
-A 1:1 coverage plan was written and implemented on 12/22/20 and updated on 7/1/21 and 1/1/22.
In addition to the above-mentioned plans, Individual #1 requires a dysphagia level II, mechanical soft diet. Valley Community Services utilizes a Fatal Four training and a "Safe Eating & Drinking" training, as well as 2 videos created by the Valley Community Services nutritionist to train staff members on how to appropriately prepare Individual #1's meals.
Staff person #10's hire date was 12/20/21, and their first date working with Individual #1 was 12/22/21. Staff person #10 did not receive training on Individual #1's 1:1 supervision plan until 3/31/22. Staff person #10 was not trained on Individual #1's staff support plan, environmental sweep plan, PICA plan, choking plan, medication refusal, medical appointment refusal, or dental hygiene plans.
Staff person #11's date of hire and first date working with Individual #1 was 2/22/21. Staff person #11 did not received training on how to appropriately prepare Individual #1's meals until 3/24/21, staff support or environmental sweep plans until 12/17/21, or 1:1 supervision plans until 3/31/22. Staff person #11 was not trained in Individual #1's medication refusal, medical appointment refusal, or dental hygiene plans.
Staff person #12's date of hire was 11/24/20. Their first date working with Individual #1 was 12/21/20. Staff person #12 was not trained on how to appropriately prepare Individual #1's meals until 10/15/21. Staff person #12 was not trained on Individual #1's staff support, medication refusal, medical appointment refusal, or dental hygiene plans.
Staff person #13's date of hire and first date working with Individual #1 was 4/12/21. Staff person #13 did not receive training on how to appropriately prepare Individual #1's meals until 4/14/21 or on Individual #1's 1:1 supervision plan until 5/26/21. Staff person #13 was not trained in Individual #1's staff support, environmental sweep, PICA, choking, medication refusal, medical appointment refusal, or dental hygiene plans.
Staff person #14's date of hire and first date working with Individual #1 was 2/25/21. Staff person #14 was not trained on Individual #1's staff support or environmental sweep plans until 12/17/21, choking, medication refusal, medical appointment refusal, or dental hygiene plans until 8/17/21, or how to appropriately prepare Individual #1's meals until 10/15/21.
Staff person #15's date of hire and first date working with Individual #1 was 10/25/21. Staff person #15 was not trained in Individual #1's ISP until 12/21/21, 1:1 supervision plan until 3/31/22, or how to appropriately prepare Individual #1's meals until 12/23/21. | The orientation must encompass the following areas: Job-related knowledge and skills. | Program Specialists have been trained on utilizing Therap for documentation of the following: Care Plans, including any Fatal Four, SEEB Plan, Supplemental Plans including refusal of Medication and/or Appointments, 1:1 Plans, along with any other specific plans for each person served such as Environmental Sweep Plan.
All trainings will continue to be live and utilize the Individual Specific Training binder. However, all plans will be loaded into Therap within the Individual Plan, Behavior Plan, or Individual Care Plan. Specific supplemental plans, such as Refusal of Medications or Refusal of Appointments are loaded into the Individual Care Plan. Each require staff to review and acknowledge. As plans are updated, they will have another live training and be acknowledged again. New hires will continue to have the live trainings, but with acknowledgement training within Therap during orientation and prior to working with the individual with the Program Manager or designee.
The Program Specialists were trained on uploading and acknowledgement reports The Program Managers and supervisory staff were trained on the new hire process of Therap Acknowledgement. Program Specialists are required to review the reports after live training to ensure acknowledgement. Program Managers are responsible for ensuring that all staff have acknowledged the information. Trainings for the Program Specialists and Program Managers were by the Quality Assurance & Training Director by 06/14/2022.
Agency-wide training with Operations Directors, Program Specialists, Program Managers, and supervisory staff was completed by 06/14/2022 on the utilization of the IDDSI information by the Director of Quality Assurance & Training. This information will be kept in the menu book for reference. Proper meal preparation was reviewed with a question-and-answer session for CLA on 06/14/2022 by Healthcare Director. Incoming staff will be trained by the Program Manager or designee on proper preparation with a return demonstration required. This will be documented in the employees training file with Human Resources. This training will include the necessity to reheat any food items that are no longer at the proper temperature. Random monitoring for CLA will be completed by the HealthCare Officer twice a month starting 06/15/2022 and ending 09/15/2022. Any issues will be immediately addressed. The Quality Assurance & Training department and the homes Operations Director will be informed, and a house-wide training will be completed within one week of the incident. |
09/15/2022
| Implemented |
| 6400.52(c)(6) | Individual #1 returned to the home on 12/21/20 after an extended hospitalization. At the time of the individual's return, multiple plans and protocols were put into place to ensure Individual #1's health and safety.
-A staff support plan was written and implemented in 11/2020.
-An environment sweep plan was written and implemented in 11/2020.
-A medication refusal and medical appointment refusal plan was written and implemented on 12/21/20 and updated on 12/7/21.
-A PICA plan was written and implemented on 12/21/20.
-A dental hygiene plan was written and implemented on 12/21/20 and updated on 12/7/21.
-A choking prevention plan was written and implemented on 12/7/20 and updated on 12/7/21.
-A 1:1 coverage plan was written and implemented on 12/22/20 and updated on 7/1/21 and 1/1/22.
In addition to the above-mentioned plans, Individual #1 requires a dysphagia level II, mechanical soft diet. Valley Community Services utilizes a Fatal Four training and a "Safe Eating & Drinking" training, as well as 2 videos created by the Valley Community Services nutritionist to train staff members on how to appropriately prepare Individual #1's meals.
Staff person #1's hire date was 4/1/19. This staff began working with Individual #1 upon their 12/21/20 return from hospitalization. Staff person #1 was not trained in Individual #1's staff support plan until 12/17/21, medication refusal, medical appointment, and dental hygiene plans until 8/17/21, and how to appropriately prepare Individual #1's meals until 3/19/21.
Staff person #2's hire date was 5/16/89. This staff began working with Individual #1 upon their 12/21/20 return from hospitalization. Staff person #2 was not trained in Individual #1's staff support plan until 12/17/21 and how to appropriately prepare Individual #1's meals until 5/30/21. Staff person #2 has not been trained in Individual #1's medication refusal, medical appointment refusal, and dental hygiene plans.
Staff person #3's hire date was 5/24/05. This staff began working with Individual #1 upon their 12/21/20 return from hospitalization. Staff person #3 was not trained in Individual #1's medication refusal, medical appointment refusal, and dental hygiene plans until 8/17/21 and how to appropriately prepare Individual #1's meals until 3/19/21. Staff person #3 was not trained on Individual #1's staff support plan.
Staff person #4's hire date was 11/13/20. This staff began working with Individual #1 upon their 12/21/20 return from hospitalization. Staff person #4 was not trained in Individual #1's staff support plan until 12/17/21. Staff person #4 was not trained on Individual #1's medication refusal, medical appointment refusal, dental hygiene plans, or how to appropriately prepare Individual #1's meals.
Staff person #5's hire date was 11/5/20. This staff began working with Individual #1 on 5/17/21. Staff person #5 was not trained on Individual #1's staff support plan or environmental sweep plan until 12/17/21. Staff person #5 was not trained on Individual #1's medication refusal, medical appointment refusal, and dental hygiene plans, or how to appropriately prepare Individual #1's meals.
Staff person #6's hire date was 10/13/16. This staff began working with Individual #1 upon their 12/21/20 return from hospitalization. Staff person #6 was not trained in Individual #1's staff support plan until 12/17/21, medication refusal, medical appointment refusal, or dental hygiene plans until 8/17/21, or how to appropriately prepare Individual #1's meals until 3/19/21.
Staff person #7's hire date was 4/2/20. This staff began working with Individual #1 on 6/1/21. Staff person #7 was not trained in Individual #1's medication refusal, medical appointment refusal, or dental hygiene plans until 8/17/21. Staff person #7 was not trained on Individual #1's staff support plan.
Staff person #8's hire date was 8/27/19. This staff began working with Individual #1 on 8/2/21. Staff person #8 was not trained in Individual #1's staff support plan, medication refusal, medical appointment refusal, or dental hygiene plans.
Staff person #9's hire date was 9/9/20. This staff began working with Individual #1 on 9/20/21. Staff person #9 was not trained on Individual #1's staff support plan, environmental sweep plan, or PICA plan until 12/17/21. Staff person #9 was not trained in Individual #1's choking plan, 1:1 supervision plan, medication refusal, medical appointment refusal, or dental hygiene plans. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | Documentation of trainings were not located for Individual #1. Agency-wide Program Specialists have been trained on utilizing Therap for documentation of the following: Care Plans, including any Fatal Four, SEE Plan, Supplemental Plans including refusal of Medication and/or Appointments, 1:1 Plans, along with any other specific plans for each person served such as Environmental Sweep Plan.
All trainings will continue to be live and utilize the Individual Specific Training binder. However, all plans will be loaded into Therap within the Individual Plan, Behavior Plan, or Individual Care Plan. Specific supplemental plans, such as Refusal of Medications or Refusal of Appointments are loaded into the Individual Care Plan. Each require staff to review and acknowledge. As plans are updated, they will have another live training and be acknowledged again. The Program Specialists were trained on uploading and acknowledgement reports Acknowledgement Reports will be available upon request.
The Program Specialists were trained on uploading and acknowledgement reports The Program Specialists are required to review the reports after live training to ensure acknowledgement. Program Managers are responsible for ensuring that all staff have acknowledged the information. Trainings for the Program Specialists and Program Managers were by the Quality Assurance & Training Director by 06/14/2022.
Agency-wide training with Operations Directors, Program Specialists, Program Managers, and supervisory staff was completed by 06/14/2022 on the utilization of the IDDSI information by the Director of Quality Assurance & Training. This information will be kept in the menu book for reference. Proper meal preparation was reviewed with a question-and-answer session for CLA on 06/14/2022 by Healthcare Director. Random monitoring for CLA will be completed by the HealthCare Officer twice a month starting 06/15/2022 and ending 09/15/2022. Any issues will be immediately addressed. The Quality Assurance & Training department and the homes Operations Director will be informed, and a house-wide training will be completed within one week of the incident. |
09/15/2022
| Implemented |
| 6400.163(h) | At the time of the 5/4/22 inspection, the medications Abreva and Mucinex were present in the home. Abreva was prescribed for a 5 day period from 3/18/22 -- 3/24/22. Mucinex was prescribed for a 30 day period from 11/1/21 -- 11/30/21. Neither medication was changed to a PRN medication after the initial prescription and should have been disposed of at the time the prescriber's order ended. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | All Program Managers and supervisory staff, which are responsible for disposing of medication once the treatment is completed, have be retrained on 6400.163(h). The training was completed by The Quality Assurance & Training Director by 06/14/2022. The outline and attendance records have been attached for review. Although Individual #1 has been ordered both Abreva and Mucinex on numerous occasions, the medication should have been disposed. The Program Manager returned to the Primary Care Physician regarding the continuous order for these medications and they are now part of Individual #1s PRNs. The original medications were removed from the home immediately and new medications have been sent by the pharmacy with the label specifying as needed.
To ensure no further infractions occur, Program Specialists will review medications within one week of discontinuation to ensure disposal is complete. The training was completed by the Quality Assurance & Training Director by 06/14/2022. Outline and attendance record are attached for review. |
06/14/2022
| Implemented |
| 6400.165(c) | Individual #1 has a PRN prescription for acetaminophen for headache or general discomfort. Individual #1 was administered acetaminophen for "congestion, slight cough, runny nose" on 4/3/22.
On 7/5/21, Individual #1's PCP ordered Abreva to be administered 5 times daily for 10 days. This medication was not administered to Individual #1 until 7/8/21.
Individual #1's PRN acetaminophen prescription is to be given as 2 tablets every 6 hours PRN. On 11/21/21, Individual #1 was administered acetaminophen at 7:30am and 1:20pm.
Individual #1 has a PRN prescription for loperamide that is to be administered after any loose stool. Individual #1 had loose stools on the following dates with no loperamide administered: 6/6/21, 6/7/21, 6/12/21, 6/19/21, 6/20/21, 6/21/21, 6/22/21, 6/23/21, 6/24/21, 6/25/21, 8/7/21, 8/8/21, 8/29/21, 10/24/21, 11/19/21, 3/17/22. | A prescription medication shall be administered as prescribed. | Over the Counter (OTC) forms, signed by the physician must be followed. Program Managers, which are trainers and/or practicum observers will retrain all medication administrators on the OTC form and the specific uses for each medication, along with the time between administrations.
Also, all medications must be started as soon as possible, typically within 24 hours of prescribing. Program Managers are retrained on the need to administer medication in a timely manner. If procurement of the medication is hampered, there must be a medical review form with both the pharmacy statement and the prescribing physician acknowledgement. Training with the Program Managers was completed by 06/14/2022 by the Quality Assurance & Training Director. The Program Managers will submit training records for all medication administrators to the Quality & Assurance department by 06/30/2022.
Individual #1 has an ileostomy. The staff are marking the type of stool found in the ileostomy bag. These stools should be thin or thick liquid, or it may be pasty. The staff have been using the correct drop-down of loose and soft. The Program Manager has returned the OTC form to the primary care physician to adjust the Loperamide. The current medication has been removed and returned to the pharmacy due to label inaccuracy. The updated OTC form with Loperamide adjustment has been sent to the pharmacy. The Loperamide with the updated instructions will be delivered to the CLA. |
06/30/2022
| Implemented |
| 6400.169(a) | Staff person #4 completed the online portion of the Modified Medication Administration Training Course on 4/3/21, however, the required handwashing, gloving, observations, and MAR reviews were not completed timely, so staff person #4 is unable to administer medications. Staff person #4 administered medications to Individual #1 in 8/2021, 9/2021, 11/2021, 12/2021, 1/2022, 2/2022, 3/2022 and 4/2022.
Staff person #7 completed the online portion of the Modified Medication Administration Training Course on 5/16/20, however the required handwashing, gloving, observations, and MAR reviews were not completed timely, so staff person #7 was unable to administer medications. Staff person #7 administered medications to Individual #1 in 6/2021, 7/2021, 8/2021, and 9/2021.
Staff person #9 completed the online portion of the Modified Medication Administration Training Course on 10/20/21, however the required handwashing, gloving, observations, and MAR reviews were not completed timely, so staff person #9 is unable to administer medications. Staff person #9 administered medications to Individual #1 in 11/2021, 12/2021, 1/2022, 2/2022, 3/2022, and 4/2022.
Staff person #14 completed the online portion of the Modified Medication Administration Training Course on 3/30/21, however the required handwashing, gloving, observations, and MAR reviews were not completed timely, so staff person #14 was unable to administer medications. Staff person #14 administered medications to Individual #1 in all months from 6/2021 through 4/2022. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | During the beginning of the Pandemic and the roll out of Appendix K, medication administration training was utilizing the Modified Medication Administration Course. However, Valley Community Services wanted to only use this in cases of emergencies. As the pandemic continued and the DSP crisis worsens, more of the Modified Medication administrators were utilized. The agency acknowledges not reviewing or following the Medication Administration Training Program Initial Training Requirements.
Staff person #9 and staff person #14 were pulled from passing medications. They have completed the standard course and their documentation is submitted for review. Valley Community Services conducted 11 courses over 2 weeks and have moved 97 Modified Medication Administrators into the standard course. Documentation reports have been sent for review.
To ensure no further infractions, all Medication Administration Trainers and Practicum Observers will ensure the four medication passes are completed within a 30-day period. Handwashing and gloving are now completed with the standard class instructions. Trainings were completed by The Quality Assurance & Training Director by 06/14/2022. Outline and attendance record are attached. |
06/14/2022
| Implemented |
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