Fremont Home Care INC

A revisit survey was completed on 3/12/24 for all previous deficiencies cited on 12/13/23. The facility is in compliance with all deficiencies that were cited. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A recertification survey was completed on 12/13/23. A deficiency was cited. Based on observation, record review and interview, the facility (residence) failed to follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII medication administration regulations, affecting six current participants (residents).Findings include: 1. Chapter VII regulations governing assisted living residences, part 14.31, requires the administrator and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Any irregularities shall be investigated and resolved. The results of the audits shall be documented and routinely included as part of the assisted living residence' s Quality Management Program assessment and review. On 12/13/23 at 7:45 a.m., the director of operations management (DOM) was requested to provide the residence' s quarterly medication cart audits; however, she was unable to provide the documentation. On 12/13/23, the DOM stated that she and Staff #3 conducted the medication cart audits every two to three months; however, she was unaware the residence was required to maintain documentation of the audits. The DOM confirmed there was no documentation of the medication cart audits.

A relicensure survey was completed on 12/13/23. A deficiency was cited. Based on record review and interview, the residence failed to ensure medication audits were completed by the administrator and qualified medication administration person (QMAP) supervisor on a quarterly basis, affecting six current residents.Findings include:On 12/13/23 at 7:45 a.m., the director of operations manager (DOM) was requested to provide the residence' s quarterly medication cart audits; however, she was unable to provide the documentation. On 12/13/23, the DOM stated that she and Staff #3 conducted the medication cart audits every two to three months; however, she was unaware the residence was required to maintain documentation of the audits. The DOM confirmed there was no documentation of the medication cart audits. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.14.29 All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident' s room location, any known allergies, and the name and telephone number of the resident' s authorized practitioner. (B) As part of the medication administration record, the assisted living residence shall maintain a legible list of the names of the persons utilizing the record for medication administration, along with each of their signatures and, if used, their initials.