Overview
DDS did not ensure that medication occurrence reports (MORs) were created and finalized by provider-operated group homes or reviewed by DDS Medication Administration Program (MAP) coordinators within the prescribed timeframes. Without timely reporting and review of MORs, there is an increased risk of poor outcomes for clients affected by staff members forgetting to administer medication, making dosage mistakes, or administering the wrong medication.
Fourteen (23%) of 60 regular MORs we reviewed were created by provider-operated group homes in an average of 44 calendar days, 37 calendar days beyond the established 7-calendar-day timeframe. DDS also did not ensure that provider-operated group homes finalized their hotline MORs within the established 24-hour timeframe: 85 (63%) of 136 hotline MORs we reviewed were finalized by provider-operated group homes in an average of 18 calendar days, 17 calendar days beyond the established timeframe. Finally, DDS MAP coordinators did not review 24 (18%) of these 136 hotline MORs within the established 14-calendar-day timeframe. These 24 hotline MORs were reviewed by a regional MAP coordinator after an average of 87 calendar days. One hotline MOR was created December 4, 2017 and had never been reviewed as of the time of our audit testing.
Authoritative Guidance
DDS’s MOR Overview Guide requires all provider-operated group homes to create and finalize hotline MORs within 24 hours after incidents are discovered. Once a provider finalizes a hotline MOR, it must be reviewed by a DDS MAP coordinator for approval within 14 calendar days. Regular MORs must be created in HCSIS within 7 calendar days after MOR events are discovered.
Reasons for Issue
DDS had not implemented effective monitoring controls in its policies and procedures to ensure that provider-operated group homes created and finalized MORs within the prescribed timeframes. DDS also stated that the volume of MORs submitted for review by MAP coordinators, along with limited staffing resources, had contributed to delays in meeting deadlines.
Recommendations
- DDS should implement effective monitoring controls in its policies and procedures to ensure that provider-operated group homes create and finalize MORs, and MAP coordinators review them, within the prescribed timeframes.
- If DDS believes that inadequate staffing is contributing to this issue, it should determine the staffing level it would need to meet the required timeframes and seek funding to reach that level.
Auditee’s Response
DDS agrees with the Auditor’s Finding that Medication Occurrence Reports (MORS) were not created, finalized, and reviewed within prescribed timeframes. DDS further agrees that MORs, and especially Hotline MORs, are extremely serious. Although in some instances the MORs and Hotline MORs were not submitted within timeframes, it is important to note that Hotline MORs are reported to the Department of Public Health (“DPH”) as well as DDS. Further, it is practice, not captured in HCSIS, for DDS MAP Coordinators to communicate directly with DPH and with the reporting Provider via phone calls and emails when they receive a Hotline MOR, and to address it immediately.
DDS agrees with the recommendation that it implement effective monitoring controls within its policies to create and finalize MORs, including their review by MAP Coordinators. DDS will implement a plan to retrain providers on the timely reporting of Hotline and non-Hotline MORs and the reporting requirement for both DPH and DDS. DDS will also work with MAP Coordinators to define how HCSIS can be used to best reflect the timing of their review of an MOR even if it is not immediately ready for final approval. In the longer term, DDS will explore whether HCSIS may be modified to include information that more accurately reflects timelines related to communication between MAP Coordinators, DPH staff, and Provider staff.
Auditor’s Reply
Based on its response, DDS is taking measures to address our concerns in this area.
| Date published: | June 29, 2021 |
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