CHARLESTON ASSISTED LIVING

Charleston Assisted Living – Plan of CorrectionSurvey Date: 8/26/2025Deficiency/Tag #: 1144Regulation Cited: Comprehensive assessments must be documented and retained in the resident’s health information record. 1. Deficiency StatementBased on record reviews and interviews, Charleston Assisted Living failed to document and retain a comprehensive assessment in the resident’s health information record. 2. Corrective Action Taken for Identified Resident(s)The missing comprehensive assessments were completed immediately for the cited resident(s) and placed in their health records on 8/27/2025. Administrator verified that all information is complete, signed, and dated. 3. Corrective Action to Identify and Protect Other ResidentsA full audit of all current resident health information records was conducted on 8/27/25 by the Administrator. Any missing or incomplete assessments were identified and corrected within 72 hours. All active residents now have a completed and retained comprehensive assessment in their files. 4. Systemic Changes to Prevent RecurrenceAdmission procedure revised: A comprehensive assessment will be completed within 24 hours of admission and filed in the resident’s record. A new admission checklist was added to every admission packet to ensure the assessment is completed, filed, and signed. Administrator will review all new admission packets within 48 hours to confirm assessment is present. The administrator will document that comprehensive, yearly, and change in status are reviewed on a quarterly audit sheet. Data will be reviewed during scheduled QAPI meetings to identify trends and areas for improvement. Targeted interventions will be implemented as needed, with ongoing monitoring to evaluate effectiveness and ensure continuous quality improvement. All findings, actions, and outcomes will be documented and maintained for staff review and regulatory compliance. Staff education provided on 8/27/2025 regarding assessment documentation and retention requirements. 5. Monitoring & Quality AssuranceAdministrator will audit 100% of new admissions for comprehensive assessments for the next 3 months. Beginning in month 4, a random audit of resident records will be conducted quarterly by administrator. Continued non-compliance will result in immediate staff re-training. 6. Completion DateAll corrective actions will be completed by 8/27/2025

Charleston Assisted Living Facility – Plan of CorrectionSurvey Date: 8/26/2025Deficiency/Tag #: 1146Regulation Cited: Comprehensive assessments must be updated when a resident’s condition changes from baseline. 1. Deficiency StatementBased on record review and interview, the residence failed to update the comprehensive assessment after a resident’s condition changed from baseline status. 2. Corrective Action Taken for Identified ResidentThe resident’s comprehensive assessment was updated on 8/27/25 to reflect the change in condition. Service plan was revised accordingly, and interventions were implemented to address new care needs. 3. Corrective Action to Identify and Protect Other ResidentsAn audit of all resident records was completed on 8/27/2025 to ensure comprehensive assessments reflected current baseline and condition changes. This audit will be done quarterly and documented on the assessment audit sheet. Any discrepancies were corrected within 72 hours. Residents and families were notified of updates where applicable. 4. Systemic Changes to Prevent RecurrencePolicy revised on 8/27/25. Comprehensive assessments must be updated within 24 hours of any change in resident condition. Staff re-educated on identifying condition changes and the requirement to notify the Administrator/house manager immediately. Administrator/house manager will review incident reports, hospital transfers, and care notes weekly to ensure timely assessment updates. 5. Monitoring & Quality AssuranceAdministrator will audit 100% of the resident charts weekly for 1 month to ensure condition changes are documented in assessments. Beginning in month 2, Administrator will conduct monthly random audits for 6 months. Audit results will be reviewed in quarterly QA/PI meetings. Noncompliance will trigger immediate staff retraining.

Charleston Assisted Living – Plan of Correction / Action PlanSurvey Date: August 26, 2025Deficiency/Tag #: 1150Regulation Cited: Each resident must have a care plan that promotes mobility and safety and details specific personal service needs, preferences, and staff tasks necessary to meet those needs. 1. Deficiency StatementBased on interviews and record review, Charleston Assisted Living failed to ensure each resident care plan promoted resident mobility and safety and detailed specific personal service needs and preferences along with the staff tasks necessary to meet those needs. 2. Corrective Action Taken for Identified ResidentsCare plans for residents cited in the survey were immediately reviewed and updated on 8/27/25. Updates included:Resident-specific mobility interventions (e.g., assistive devices, staff transfer techniques). Safety interventions (e.g., fall prevention, call light use, environmental modifications). Detailed personal service needs and resident preferences (bathing, meals, daily routine, activities). Clear staff tasks to meet identified needs. 3. Corrective Action to Identify and Protect Other ResidentsA facility-wide audit of all resident care plans was conducted on 8/27/2025-9/1/2025. Any missing mobility, safety, or preference details were corrected immediately. All current residents now have a comprehensive, individualized care plan on file. Care plans will be reviewed and documented quarterly on the careplan audit sheet. Data will be reviewed during scheduled QAPI meetings to identify trends and areas for improvement. Targeted interventions will be implemented as needed, with ongoing monitoring to evaluate effectiveness and ensure continuous quality improvement 4. Systemic Changes to Prevent RecurrenceCare Plan Policy revised on 8/29/25. Care plans must include mobility supports, safety interventions, individualized service needs, preferences, and staff responsibilities. Updates required within 24 hours of any change in condition. Standardized Care Plan Template implemented to ensure consistent documentation of:ADLs, mobility needs, safety interventions, resident preferences, and specific staff tasks. Administrator and house manager discussed oversight responsibilities to verify care plan completeness. 5. Monitoring & Quality AssuranceAdministrator will review 100% of the care plans weekly for 1 month. Administer/house manager will audit 100% of the care plans quarterly. Any staff found noncompliant will receive immediate re-education.

Charleston Assisted Living – Plan of CorrectionSurvey Date: 08/26/2025Deficiency/Tag #: 2230Regulation Cited: Resident records must contain a facesheet, individualized care plan, and documentation of ongoing services provided by external service providers. 1. Deficiency StatementBased on record reviews and interviews, Charleston Assisted Living failed to ensure resident records contained a facesheet, individualized care plan, and documentation of ongoing services provided by external service providers. 2. Corrective Action Taken for Identified ResidentsMissing facesheets and care plans were completed and filed in resident records on 8/27/25. Documentation of ongoing services from external providers (e.g., PT, OT, home health, hospice) was obtained and filed for all affected residents on 9/22/25. Administrator verified completeness and accuracy of all updates. 3. Corrective Action to Identify and Protect Other ResidentsAudit of all current resident records conducted on 8/28/25 to ensure:Each record has a current facesheetAn individualized care plan is presentDocumentation of all ongoing external services is includedAny missing or incomplete records corrected immediately. 4. Systemic Changes to Prevent RecurrencePolicy updated on 8/27/25: All resident records must include:Current facesheetIndividualized care planDocumentation of ongoing external servicesStandardized Admission Checklist was implemented to ensure each record is complete at admission and updated quarterly or as changes occur. Administrator/house manager responsible for reviewing new admissions and quarterly updates to ensure compliance. 5. Monitoring & Quality AssuranceAdministrator/house manager to audit 100% of records weekly for 1 month to confirm completeness. Starting month 2, 100% of records will be audited quarterly. Audit findings documented and recorded on quarterly audit sheets and reviewed during QA meetings. Noncompliant staff will receive immediate re-education.

Correction Plan for Missing Certifications in Employee Files (CPR, CAPS, QMAP) for the State of ColoradoObjective:Ensure compliance with state regulations and organizational policies by addressing gaps in employee certifications, including CPR, CAPS check, and QMAP, and ensure all employee files are fully updated with required documents. 1. Immediate Action Plan (Within 30 days)Step 1: Identify GapsAssign a team: Designate house manager to audit employee files for missing certifications. Prepare a report: Create a comprehensive list of employees with missing certifications (CPR, CAPS, QMAP). Categorize gaps: Separate employees into categories based on which certifications are missing (e.g., CPR, CAPS, QMAP). Step 2: Notify EmployeesCreate notification templates: Prepare emails or formal letters notifying employees about missing certifications. Set deadlines: Establish a clear deadline (e.g., within 2 weeks) for employees to submit or update their certifications. Step 3: Coordinate Training and CertificationOrganize CPR and QMAP certification classes:Work with approved training organizations to schedule CPR and QMAP courses. Provide employees with accessible options (e.g., in-person or online courses). Ensure all employees in need of CPR and QMAP certification are registered and attend the training. CAPS check process:Review CAPS check requirements and ensure that all employees undergo background checks if not already completed. Coordinate with the relevant department to update or complete CAPS checks for employees. 2. Mid-Term Action Plan (Within 60-90 days)Step 4: Verification and DocumentationTrack progress: Maintain a spreadsheet or database of employees who have completed the necessary training or certification. Update employee files: Ensure that certification documents (CPR, CAPS, QMAP) are properly filed and stored in each employee’s personnel record. Review employee progress: Cross-reference the list of employees who were notified to confirm they have submitted or updated their certifications. Step 5: Address Non-ComplianceFollow-up reminders: Send follow-up emails or letters to employees who have not yet provided certifications, offering assistance or guidance on completing training. Disciplinary action: If employees fail to complete required certifications after multiple reminders, escalate for possible disciplinary action. 3. Long-Term Preventative ActionsStep 6: Update Onboarding ProceduresAdd certification requirements to onboarding: Include CPR, CAPS, and QMAP certification verification as part of the hiring and onboarding process for all new employees. Automated reminders: Set up automated email or system reminders for certifications that are approaching expiration or need to be renewed. Step 7: Regular AuditsConduct quarterly audits: Implement a regular audit schedule (e.g., quarterly or semi-annually) to ensure all employees’ certifications are up to date. Create a tracking system: Set up a digital tracking system to monitor and flag expired certifications well before renewal dates. Step 8: Continuous Education and TrainingOffer recurring training: Provide opportunities for employees to refresh or renew certifications (CPR, CAPS, QMAP) on an annual or bi-annual basis. Provide incentives: Consider offering incentives or recognition for employees who maintain up-to-date certifications and contribute to a culture of compliance. 4. Resources and SupportTraining Providers: Identify reputable organizations that provide CPR, CAPS, and QMAP certifications. Internal Support: House managers, and training coordinators should be available to assist employees with the certification process. Budgeting for Training: Ensure adequate funding for training programs, including any necessary materials or fees for employees who need certifications. 5. Communication PlanTransparent Updates: Communicate to all employees the importance of keeping certifications current and how to go about submitting or updating their documents. Regular check-ins: Schedule regular team meetings to monitor progress on the certification process. Clear contact points: Establish a clear process for employees to reach out to HR or training coordinators for assistance with certifications. 6. Evaluation and ReportingReview success: Evaluate the effectiveness of the correction plan after the 90-day mark. Are all certifications up to date? Was the process smooth and efficient?Feedback loop: Request feedback from employees on the process to identify areas for improvement. Reporting to stakeholders: Provide regular updates to management about progress and completion of certification updates. This correction plan ensures both immediate compliance and long-term sustainability of certification management, promoting a well-trained and legally compliant workforce.

Plan of Correction for Ensuring All Employees Obtain CPR Certification from a Nationally Recognized Organization Objective:Ensure that all employees of the organization obtain and maintain CPR certification from a nationally recognized organization, in compliance with state regulations and organizational policies. Additionally, ensure that at least one employee with CPR certification is always present on-site during operating hours. 1. Immediate Action Plan (Within 30 Days)Step 1: Audit Employee CPR Certification StatusDesignate a team: Assign house manager to review and audit current employee files to identify those who are missing CPR certifications. Compile a report: Prepare a list of employees who do not have a valid CPR certification, ensuring that the certification is from a nationally recognized organization (e.g., American Heart Association, American Red Cross). Set a clear deadline: Establish a timeline for compliance, such as 30 days from the audit to ensure all employees have completed CPR certification or are enrolled in upcoming classes. Step 2: Notify Employees of Missing CertificationCreate a notification template: Prepare an email or formal letter that notifies employees of the requirement to obtain CPR certification, including details on the nationally recognized organizations they can choose from. Clear instructions: Provide employees with easy-to-follow steps on how to obtain certification, including options in-person courses and a list of approved certification providers. Set a deadline for submission: Give employees a firm deadline (e.g., within two weeks) to submit proof of their CPR certification or confirm their registration for a CPR course. 2. Immediate Training Plan (Within 30-60 Days)Step 3: Organize CPR Certification CoursesCoordinate with training providers: Reach out to nationally recognized CPR certification organizations (e.g., American Heart Association, American Red Cross) to schedule on-site or virtual courses for employees who need certification. Group training sessions: Offer group training sessions to make it easier and more cost-effective for employees to obtain CPR certification. Provide financial support: If necessary, allocate funds or reimburse employees for the cost of CPR certification courses to ensure all employees can participate. Step 4: Track Employee ProgressMaintain a tracking system: Develop a system to track employee registration for CPR courses and monitor completion status. Confirm certification completion: Ensure that employees provide proof of certification once completed (e.g., digital certification or training card). Send reminders: For employees who have not yet completed the certification, send reminder emails or notices with a firm deadline. 3. Mid-Term Action Plan (Within 60-90 Days)Step 5: Verify and Update Employee FilesCertification verification: Once employees have completed their CPR certification, verify that the certification is from a nationally recognized organization. File updates: Ensure that all employee records are updated with valid CPR certification documentation and stored securely. Ensure compliance: Review the updated employee files to ensure no employee is left without certification or proof of completion. Step 6: Address Non-ComplianceFinal reminders: If employees fail to submit their certifications by the deadline, send a final notice informing them of the consequences of non-compliance, including possible disciplinary actions. Provide alternative options: Offer employees alternative courses or resources if they are unable to attend the scheduled training. Escalate as necessary: For employees who do not meet the certification requirement, management should intervene to ensure compliance, including possible consequences. 4. Long-Term Preventative ActionsStep 7: Update Onboarding and Training ProceduresCPR certification requirement for new hires: Implement a policy that requires all new hires to obtain CPR certification from a nationally recognized organizationas part of the onboarding process. Onboarding checklist: Include CPR certification verification in the onboarding checklist, ensuring all employees have received or are scheduled to receive CPR training before starting their duties. Training reminders: Set up automated reminders for employees to renew their certifications before they expire. Step 8: Ongoing Training and RecertificationAnnual CPR recertification: Develop a system for ensuring that all employees maintain CPR certification, with reminders to renew certifications as required (typically every two years). Scheduled training sessions: Set up recurring CPR training courses on an annual or bi-annual basis to accommodate employees who need recertification. Incentives for certification: Consider implementing incentives for employees who stay current with CPR certification or complete additional life-saving skills courses. Step 9: Ensure On-Site CPR Certification CoverageStaffing plan for CPR coverage: Develop a staffing plan to ensure that at least one employee with CPR certification is always on-site during business hours. Schedule rotation: If necessary, establish a rotation of CPR-certified employees so that coverage is guaranteed at all times. Emergency response protocol: Ensure that in the event an employee with CPR certification is unavailable, a trained backup can be identified or scheduled. 5. Communication PlanStep 10: Communicate the Importance of CPR CertificationInternal communication: Regularly remind employees about the importance of CPR certification for safety and compliance, via emails, staff meetings, or internal newsletters. Highlight benefits: Emphasize how CPR certification helps to create a safer workplace and aligns with the organization's commitment to employee well-being and regulatory compliance. Step 11: Transparent ReportingProvide status updates: Communicate progress regularly to employees and management, providing updates on the number of employees who have completed or are in the process of obtaining their CPR certification. Clear contact points: Ensure that employees know who to contact for assistance with scheduling, certifying, or submitting their CPR documentation. 6. Evaluation and ReportingStep 12: Review Plan EffectivenessAssess compliance: At the 90-day mark, review whether all employees are CPR certified and if the process has been efficient and effective. Request employee feedback: Gather feedback from employees about the process, any challenges they faced in obtaining CPR certification, and suggestions for improvement. Report to Administrator: Provide a final report to administrator, such as management or regulatory bodies, detailing the steps taken, compliance achieved, and future plans to ensure ongoing certification. 7. Resources and SupportTraining providers: Collaborate with recognized organizations such as the American Heart Association or the American Red Cross to facilitate courses and certification. Internal support: Management should be available to assist employees with scheduling training or understanding certification requirements. Budgeting: Allocate a budget to cover training costs for employees who need CPR certification or recertification. 8. Evaluation MetricsCertification completion rate: Track the percentage of employees who complete CPR certification within the designated timeline. Non-compliance rates: Measure how many employees failed to meet the certification deadline and assess the effectiveness of follow-up actions. Feedback satisfaction: Gather employee satisfaction feedback on the training process and resources offered. On-site CPR coverage: Measure the effectiveness of the on-site CPR staffing plan, ensuring that at least one CPR-certified employee is always present during business hours. This correction plan ensures that all employees obtain CPR certification from a nationally recognized organization, meets state regulatory requirements, improves the overall safety of the workplace, and guarantees that there is always at least one CPR-certified employee on-site to provide immediate assistance if needed.

Plan of Correction for Resident Roster, Room Diagram, and Emergency Contact InformationObjective:Ensure that the residence maintains a readily accessible roster of current residents, a residence diagram showing room locations, and up-to-date emergency contact information, in compliance with state regulations. 1. Immediate Action Plan (Within 30 Days)Step 1: Review Current DocumentationAssign a team: Designate house manager to review current records and ensure that a roster of current residents, a diagram showing room locations, and emergency contact information are in place. Identify gaps: Determine if any of the required documents (roster, diagram, or emergency contact information) are missing or incomplete. If they are missing, immediately create or update these records. Ensure completeness: Review the existing documentation to ensure it is up-to-date, accurate, and readily accessible. Confirm that all necessary details (resident names, room assignments, and contact information) are included. Step 2: Develop and Implement a Corrective Action PlanRoster of current residents: Create a comprehensive roster of all current residents, including full names, room numbers, and pertinent medical or dietary information. Ensure this roster is updated in real-time, whenever there are changes (e.g., new admissions, discharges). Room diagram: Develop a clear, up-to-date diagram of the residence, including room locations and identification, ensuring the diagram is simple to read and accessible to staff. Mark locations of resident rooms, common areas, exits, and emergency equipment. Emergency contact information: Compile and update emergency contact information for each resident, ensuring that contacts include family members, guardians, and medical professionals. This should be kept up to date and readily available to staff in case of an emergency. Step 3: Ensure Readily Accessible DocumentsPhysical accessibility: Ensure that the roster, diagram, and emergency contact information are available in a physical location within the facility (e.g., at the front desk, nursing station, or facility office). Digital accessibility: Additionally, make sure these documents are available electronically on the organization's internal network or electronic medical record system (EMR) for easy access by authorized staff members. Notify staff: Communicate with all staff that these documents must be readily accessible at all times and ensure they know where to find them in case of an emergency or immediate need. 2. Mid-Term Action Plan (Within 60-90 Days)Step 4: Establish a System for Continuous UpdatesCreate update protocol: Implement a standard operating procedure (SOP) for regularly updating the roster, room diagram, and emergency contact information. This should include the following:Roster updates: Update resident information whenever a new resident is admitted or an existing resident is discharged, and ensure that staff is immediately informed of any changes. Room diagram maintenance: Review and update the room diagram at least quarterly or whenever there are structural changes to the residence (e.g., room reassignment, renovations). Emergency contact updates: Ensure that emergency contact information is updated during regular care plan reviews or at least annually. Also, confirm changes in emergency contacts (such as phone numbers or guardians) during resident check-ins. Step 5: Conduct Staff TrainingTrain staff on access protocols: Conduct a training session for all staff members to ensure they know how to access and update the resident roster, room diagram, and emergency contact information. Emphasize importance: Highlight the importance of having these documents readily available at all times for resident safety and emergency preparedness. Provide written guidelines: Distribute written protocols that staff must follow for updating and maintaining these documents. This ensures that everyone understands their responsibility and the steps involved in keeping this information current. 3. Long-Term Preventative ActionsStep 6: Implement Ongoing MonitoringAssign a responsible person: Designate a specific staff member (e.g., facility administrator or house manager) to be responsible for overseeing the ongoing maintenance of the roster, room diagram, and emergency contact information. Regular audits: Schedule regular audits (e.g., monthly or quarterly) to ensure that the roster, room diagram, and emergency contact information are always up-to-date and accessible. Incorporate into facility inspection: As part of routine internal facility inspections, ensure that these documents are checked for accessibility, accuracy, and completeness. Step 7: Automate Where PossibleAutomated alerts: Set up automated alerts for staff to remind them when an update is needed for the roster or emergency contacts. Step 8: Regularly Review and Update PoliciesReview policies annually: Ensure that the facility's policies on maintaining and accessing resident rosters, room diagrams, and emergency contact information are reviewed at least annually for compliance with state regulations and best practices. Incorporate feedback: Gather feedback from staff during training sessions or audits to identify any challenges they face in accessing or maintaining these documents, and adjust procedures accordingly. 4. Communication PlanStep 9: Communicate ChangesInternal communication: Regularly update facility management and staff on the status of the corrective actions. Provide updates on any new procedures, training sessions, or audits conducted. External communication: Communicate with residents and their families about any updates to emergency contact information and reassure them that their safety is a top priority. Clear points of contact: Provide staff with clear points of contact (e.g., admin, facility manager) should they encounter issues with accessing or updating the documents. 5. Evaluation and ReportingStep 10: Review Plan EffectivenessMonitor compliance: After 90 days, assess whether the corrective actions have been successfully implemented and if the residence is consistently maintaining and updating the required documents. Conduct a facility-wide audit: Perform a full review of the current roster, room diagram, and emergency contact information to ensure they are all readily accessible and accurate. Evaluate staff compliance: Check with staff members to ensure they know where to locate these documents and understand their responsibilities for keeping them up to date. Step 11: Continuous ImprovementFeedback loop: Request feedback from staff about the ease of access to the documents, any challenges they faced in the process, and suggestions for improving the system. Report to relevant authorities: Submit a final report to relevant stakeholders (e.g., state regulators, facility management) detailing the actions taken, compliance achieved, and plans for continued monitoring and improvement. 6. Resources and SupportTools for diagramming: Use software like Microsoft Visio, Google Drawings, or specialized facility management software to create and maintain room diagrams. Training resources: Provide staff with training materials that highlight the importance of keeping documents accessible and up-to-date. 7. Evaluation MetricsDocument accessibility: Measure the ease of access to the roster, room diagram, and emergency contact information by staff. Update compliance: Track the timeliness and accuracy of updates to the resident roster, room diagram, and emergency contact information. Staff training completion: Monitor the completion of staff training on the new procedures for maintaining these records. By following this plan, the residence will ensure compliance with state requirements for maintaining an up-to-date and accessible roster of residents, room diagrams, and emergency contact information, enhancing the overall safety and preparedness of the facility.

Plan of Correction to Ensure Accurate and Timely Medication Administration Documentation by Qualified Medication Administration Personnel (QMAP)Objective:To ensure that all Qualified Medication Administration Personnel (QMAP) accurately document each medication administration immediately after the event is completed for every resident, including documenting the reason for PRN medications, their effectiveness, and ensuring that any medications not administered are properly documented with the reason for omission on the back of the Medication Administration Record (MAR). 1. Immediate Action Plan (Within 30 Days)Step 1: Conduct an Immediate Audit of Medication Administration DocumentationAudit existing records: Assign a team (e.g., housing manager and QMAP) to review recent medication administration records for accuracy and timeliness. Identify any instances where medication was not documented immediately after administration, including missed medications. PRN documentation audit: Specifically review records for PRN medications to ensure that QMAPs are documenting the reason for administration and whether the medication was effective. Missed medication audit: Identify any instances where medications were not administered. Ensure that for all missed doses, the MAR is correctly circled and that the reason for non-administration is documented on the back of the MAR, as required. Corrective list: Create a list of any employees or shifts where documentation errors were identified, and address any specific gaps in training or workflow processes. Step 2: Notify QMAPs and Staff of Immediate Requirement for Timely DocumentationStaff notification: Immediately inform all QMAPs and relevant staff that medication administration must be documented immediately after the medication is given to each resident, and any medications not administered must be circled on the MAR with the reason for non-administration documented on the back. Remind staff that failing to do so could result in medication errors, safety risks, and regulatory citations. Reinforce policy: Reinforce the existing policy that requires QMAPs to document each medication administration on the medication administration record (MAR) immediately upon completion, without delay. Emphasize the requirement that if a medication is not given, QMAPs must circle the dose on the MAR and document the reason for omission on the back of the MAR.Ensure that PRN medications must include the reason for administration and whether the medication was effective. Written reminder: Provide a written reminder of this policy and expectation to all QMAPs and supervisory staff. 2. Mid-Term Action Plan (Within 60-90 Days)Step 3: Provide Refresher Training on Medication Administration and DocumentationMandatory training sessions: Conduct a series of refresher training sessions for all QMAPs. The training will focus on:The importance of documenting medications immediately after administration. Correct procedures for completing MARs in a timely and accurate manner. How to prevent common errors in documentation, including proper charting practices and protocols for any missed doses. Specific emphasis on documenting the reason for PRN medications and effectiveness of the medication administered. Documenting missed medications: How to circle missed doses on the MAR and accurately document the reason for non-administration on the back of the MAR.Simulated exercises: Include role-playing or simulated medication administration exercises where QMAPs practice both administering medication and documenting it immediately in a controlled environment, including documentation of missed medications. Supervisor-led sessions: Supervisors should hold small group sessions with QMAPs to discuss challenges, clarify expectations, and answer any questions related to documentation procedures, including the proper documentation for PRN and missed medications. Step 4: Monitor QMAP Adherence to Documentation PoliciesMonitor documentation: Supervisors should perform spot checks or conduct daily audits of medication administration records to ensure that QMAPs are documenting medications at the time they are administered, without delay. Specifically, ensure that for any missed medications, QMAPs are circling the dose on the MAR and documenting the reason for non-administration on the back. Ensure that PRN medications have the reason for administration and the effectiveness of the medication documented. Address non-compliance: For any QMAP who fails to document medications immediately, including circling missed doses and documenting reasons, supervisors should provide additional training, coaching, or corrective action, as appropriate. 3. Long-Term Preventative ActionsStep 5: Integrate Medication Administration Documentation into Daily OperationsOngoing quality assurance: Make medication documentation part of the facility’s daily quality assurance (QA) program. Ensure that medication documentation, including the documentation of PRN medications and missed medications, is included in routine audits and review processes conducted by supervisory staff. Documentation compliance reports: Generate documentation to assess the timeliness and accuracy of medication documentation, particularly focusing on PRN medication reason, effectiveness, and missed medication documentation. Facility-wide communication: Regularly communicate the importance of accurate and timely documentation across the facility, ensuring that all team members are on the same page regarding medication administration and documentation expectations. Step 6: Establish Consequences for Documentation FailuresClear policies on consequences: Establish and communicate clear consequences for repeated failure to document medication administration accurately and in a timely manner, including failing to circle missed doses or document the reason for non-administration, as well as PRN medication documentation. These could include:Additional training or mentoring for QMAPs who struggle with timely documentation. Performance improvement plans for individuals with consistent documentation failures. Progressive discipline for non-compliance, depending on the severity and frequency of errors. Incentives for compliance: Consider implementing a system of positive reinforcement for QMAPs who consistently document medication administration accurately and on time, including proper documentation for missed and PRN medications. Step 7: Implement Ongoing Education and TrainingContinuous education: Ensure that all new hires, especially QMAPs, receive proper training on medication documentation as part of their onboarding process. Annual refresher courses: Offer annual training on medication administration and documentation for all QMAPs, ensuring that everyone is updated on any changes to protocols, regulations, or system tools, including the documentation of missed and PRN medications. Resident-specific documentation review: During care plan meetings or annual reviews, include a section dedicated to reviewing the documentation of medications for each resident to ensure that the records remain up-to-date and accurate, especially regarding missed and PRN medications. 4. Communication PlanStep 8: Communicate Corrective Actions Internal communication: Regularly update facility management, QMAPs, and supervisory staff on the progress of the corrective actions. Keep the team informed of training schedules, audits, and any changes to policies or procedures. Resident and family notification: If necessary, notify residents and their families of the corrective actions being taken to improve medication administration documentation and ensure their safety, including documentation for missed and PRN medications. 5. Evaluation and ReportingStep 9: Evaluate the Effectiveness of the Corrective Action PlanMonitor compliance: After the 90-day period, review compliance data, including audit results, documentation timeliness, and feedback from QMAPs and supervisors, to assess the effectiveness of the corrective actions. Survey staff feedback: Gather feedback from QMAPs and supervisors regarding the clarity of the documentation expectations, the training sessions, and any ongoing challenges they may face, specifically in documenting missed and PRN medications. Final report: Prepare a final report summarizing the corrective actions taken, improvements made, and any further recommendations for continuous improvement. This report should be submitted to administration. Step 10: Continue Monitoring and ImprovementOngoing audits: Continue performing regular audits to ensure ongoing adherence to the new documentation procedures. Supervisors should check documentation practices at least weekly for the first three months following the plan's implementation, and monthly thereafter. Specifically, monitor the documentation of missed and PRN medications to ensure proper procedures are being followed. Feedback loop: Set up a feedback loop with staff to identify challenges, opportunities for improvement, or new tools that could help streamline medication administration and documentation, particularly for missed and PRN medications. 6. Resources and SupportTraining materials: Provide access to up-to-date training materials for QMAPs, including policy documents and step-by-step guides. Documentation tools: If the facility does not already use an eMAR system, consider investing in software or devices that support real-time documentation of medication administration. Consider training staff to use mobile devices or tablets for quicker and more accurate documentation. 7. Evaluation MetricsDocumentation timeliness: Measure the percentage of medication administrations that are documented immediately after the event, ensuring it meets the compliance requirement. Missed medication documentation: Track the percentage of missed medications that are correctly circled on the MAR and have the reason for omission documented on the back. PRN documentation: Track the percentage of PRN medication administrations that include the reason for administration and whether the medication was effective. Error rate: Track the frequency of documentation errors (e.g., missed entries, incorrect entries) and work to reduce them. Training completion: Monitor the completion of refresher training for QMAPs and staff, ensuring full participation. Audit results: Evaluate audit results on medication documentation compliance, with a focus on missed and PRN medications, to ensure the corrective actions are successful. By following this enhanced plan, the facility will ensure that all Qualified Medication Administration Personnel (QMAPs) are accurately and promptly documenting medication administration, including the reason for PRN medications, effectiveness of PRN medications, and documentation of missed medications with the reason for non-administration. This will reduce the risk of medication errors, ensure compliance with state regulations, and improve resident safety.

Plan of Correction for Conducting Quarterly Audits of Medication Administration Records (MARs) and Ensure Alignment with Providers' OrdersObjective:To ensure that the facility conducts quarterly audits of the Medication Administration Records (MARs) for all residents to verify the accuracy and completeness of the records. Additionally, the facility will ensure that all providers' orders are properly reflected in the MAR, including any new medications or the discontinuation of any medications, in accordance with state regulations and facility policies. 1. Immediate Action Plan (Within 30 Days)Step 1: Conduct an Immediate Review of MARs and Providers' OrdersImmediate audit of MARs: Perform a comprehensive review of the Medication Administration Records (MARs) for all residents, focusing on:Verifying that providers' orders match any new medications prescribed and any medications that have been discontinued. Ensuring medications are documented accurately, including administration times and dosages. Checking that missed medications are documented correctly, with reasons for non-administration and missed PRN medications noted, including effectiveness. Identify discrepancies: Identify discrepancies between providers' orders and the MAR, especially regarding newly prescribed medications or medications that should have been discontinued. Corrective actions: Address any discrepancies immediately by re-documenting medications, ensuring proper alignment with the provider's orders, and notifying the prescribing provider as needed. Step 2: Notify Staff of New Audit Procedures and Policy ChangeStaff notification: Immediately inform relevant staff (QMAPs, nurses, pharmacy, and administrative personnel) about the requirement to ensure all providers' orders are reflected in the MAR, specifically focusing on:New medications and changes to existing medications. Discontinuation of medications. Temporary audit schedule: Establish a temporary audit schedule to review all MARs and providers' orders before the formal quarterly schedule begins. The first audit should be conducted within the next 30 days. 2. Mid-Term Action Plan (Within 60-90 Days)Step 3: Establish a Formal Quarterly Audit ProcessDevelop audit protocol: Develop and formalize a written protocol for conducting quarterly audits of the MARs, ensuring all new medications and discontinued medications are aligned with providers' orders. This protocol will include:Audit team: Designate individuals responsible for auditing MARs and providers' orders (e.g., nursing staff, compliance officer, quality assurance team). Audit criteria: Define key audit criteria, including:Verifying that providers' orders match the medications listed on the MAR, especially for newly prescribed or discontinued medications. Checking for accuracy and completeness of documentation for administered medications, including missed doses and PRN medications. Ensuring that reasons for missed medications are clearly noted and documented on the back of the MAR.Ensuring PRN medications include the reason for administration and whether the medication was effective. Audit frequency: Establish a formal quarterly audit schedule, ensuring audits are performed every three months, and specify exact dates for the upcoming year. Step 4: Train Staff on the New Audit Process and Providers' Order AlignmentTraining on audit procedures: Provide training for staff involved in the audits on:The process for verifying that providers' orders match medications on the MAR, including the addition of new medications and discontinuation of medications. How to identify discrepancies between providers' orders and MAR entries and how to resolve them. Proper procedures for documenting new medications, discontinued medications, and missed doses. Ensuring PRN medications have the reason for administration and effectiveness documented. Simulated exercises: Conduct simulated exercises where QMAPs and nursing staff practice verifying MAR entries against providers' orders, including handling new medications and discontinued orders. Step 5: Conduct the First Formal Quarterly AuditAudit schedule: Complete the first formal quarterly audit as per the newly established protocol. The audit should include a thorough review of providers' orders and MARs, ensuring all new medications and discontinuations are accurately reflected. Audit report: Document the findings of the audit, including any discrepancies, issues found, and corrective actions taken. Share the results with staff and management for further review and necessary follow-up. 3. Long-Term Preventative ActionsStep 6: Integrate MAR Audits into Routine Quality Assurance ProcessesOngoing quarterly audits: Ensure that quarterly audits of the MARs, with a focus on verifying the alignment with providers' orders, become part of the facility’s routine quality assurance (QA) program. Schedule audits to occur every three months and ensure they are consistently completed. Regular review of providers' orders: As part of each quarterly audit, verify that all new medications, dosage changes, and discontinued medications are accurately reflected in the MAR.Documentation in QA reviews: Include the results of the MAR audits and the review of providers' orders in regular QA meetings. Supervisors and quality assurance teams should review the audit findings and address any systemic issues. Step 7: Implement Corrective Action for Identified IssuesAddress discrepancies immediately: If discrepancies between providers' orders and MARs are identified during audits (e.g., new medications not documented or discontinued medications still listed), implement corrective actions such as:Re-documenting MARs: Correct any medication errors immediately and ensure that the providers' orders are accurately reflected. Notifying prescribing providers: Notify the prescribing provider of any discrepancies between the MAR and providers' orders and obtain clarification or updated orders as needed. Additional training: Provide additional training for staff involved in medication administration and documentation, especially if discrepancies are recurring. Follow-up audits: Conduct follow-up audits for areas or shifts with recurring issues to ensure corrective actions have been successfully implemented. Step 8: Continuous Education and TrainingOngoing education: Ensure all new staff receive training on the importance of verifying providers' orders and the MAR as part of their onboarding. Provide regular refresher training for existing staff to ensure they stay current with documentation and medication administration policies. Annual updates: Conduct annual training sessions to review any updates to the audit process, providers' order documentation, and medication administration protocols, with an emphasis on proper documentation for new and discontinued medications. 4. Communication PlanStep 9: Communicate Corrective Actions to All StakeholdersInternal communication: Regularly update facility management, QMAPs, nursing staff, and supervisory personnel on the progress of the corrective actions. Share the findings of audits and any improvements made, with a specific focus on ensuring providers' orders match the MAR.Resident and family notification: If necessary, notify residents and their families about the corrective actions being taken to ensure accurate medication documentation and the alignment of MARs with providers' orders. 5. Evaluation and ReportingStep 10: Evaluate the Effectiveness of the Corrective Action PlanReview audit results: After each quarterly audit, review the findings to determine whether the accuracy of MAR documentation has improved, particularly focusing on the alignment of new medications and discontinued medications with providers' orders. Feedback from staff: Gather feedback from staff involved in the auditing process to identify any challenges or barriers to ensuring providers' orders are accurately reflected in the MAR.Adjustments and improvements: Based on audit results and staff feedback, make adjustments to the training or auditing process to further improve the accuracy of medication documentation. Step 11: Ongoing Monitoring and ComplianceEnsure continued compliance: Continue performing quarterly audits and ensuring that any discrepancies between providers' orders and MARs are promptly addressed. Supervisors should review MARs and providers' orders on an ongoing basis to ensure compliance. Audit follow-up: Supervisors should follow up with staff to ensure that discrepancies are corrected and that the MARs are in alignment with providers' orders, particularly for newly prescribed or discontinued medications. 6. Resources and SupportTraining materials: Provide staff with detailed training materials on the audit process, the importance of aligning providers' orders with MARs, and proper documentation procedures. Audit tools: If necessary, invest in additional tools or software to streamline the auditing process and ensure that discrepancies between providers' orders and MARs are easily identified. Documentation guidelines: Ensure all staff have clear guidelines on proper MAR documentation and the audit process, with specific focus on ensuring that providers' orders are accurately reflected. 7. Evaluation MetricsAudit completion rate: Track the completion rate of the quarterly audits and ensure that they are performed on time and with full adherence to the protocol. Discrepancy rate: Measure the number and types of discrepancies identified during the audits, particularly focusing on discrepancies between providers' orders and MARs. Training completion: Monitor the completion rate of training for all staff involved in the auditing process, ensuring full participation. Corrective action compliance: Track the effectiveness of corrective actions, ensuring that any issues identified during audits are promptly addressed and resolved. By following this enhanced plan, the facility will ensure that quarterly audits of MARs are conducted thoroughly, ensuring the accuracy and completeness of medication records. Additionally, the facility will guarantee that all medications, including new prescriptions and discontinued medications, align with providers' orders, improving resident safety, ensuring compliance, and reducing the risk of medication errors.