| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Individual 1's bedframe was unsanitary and smeared with blood. Protective plate over individual #1's iPad was smeared with blood | Clean and sanitary conditions shall be maintained in the home. | Directed Plan:
Direct Support Professionals Will Clean and disinfect Individual 1's bedframe Immediately when soiled and disinfect bedframe using EPA-approved disinfectant per infection control protocol. DSPs will Document cleaning on log sheet. DSPs will Clean and disinfect protective plate on individual #1's iPad and disinfect with approved electronic-safe wipes per protocol. DSPs will Document on cleaning log. |
| Not Implemented |
| 6400.81(k)(2) | There is no mattress in Individual 1's bedroom | In bedrooms, each individual shall have the following: A clean, comfortable mattress and solid foundation. | Directed Plan:
A mattress is onsite and available to Individual 1 if they choose to have it back in their bedroom. At this time, individual 1 is preferring to sleep in their "tent" on the floor and has rejected repeated offers of the mattress, which is on site and available to individual 1 at any time. Direct Support Professionals will document the attempts to offer and the individual's refusal daily. |
| Not Implemented |
| 6400.81(k)(3) | No bedding was observed in Individual 1's bedroom | In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season. | Directed Plan:
Bed linens and blankets are onsite and available to Individual 1 if they choose to use them. At this time, individual 1 is preferring to sleep in their "tent" on the floor with 2 blankets inside and has not accepted repeated offers of a new mattress with bed linens, which is on site and available to him at any time. Direct Support Professional will document the repeated offers and individual 1's refusal daily. |
| Not Implemented |
| 6400.144 | The following medications were not available in the home for Individual 1; however, were listed on the MAR: Orajel 3x Medicated Oral Pain Gel .25oz, Medihoney 100% Paste | 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.
| Both of these medications were available in the home, but were not stored in the primary med box as they should have been. Items were located in the refrigerator and replaced into the med box on the date of inspection. |
05/05/2025
| Implemented |
| 6400.24 | For Individual 1, Controlled Substance Count Logs are not being completed for Lorazepam or Clonazepam | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | Lorazepam medication was inappropriately prescribed and was discontinued. There is a count sheet in place for the PRN Clonazepam and a picture of this was provideed. |
05/22/2025
| Implemented |
| 6400.32(h) | Cameras are in use inside and outside the home, including in individual 1's bedroom. Without exception, the use of cameras or video monitoring equipment in bedrooms and bathrooms is strictly prohibited. Individual 1's bedroom door has a window. | An individual has the right to privacy of person and possessions. | The bedroom camera was removed on 5/3/2025 and photographic evidence was provided. Individual 1's bedroom door has a window which has been covered now. |
05/22/2025
| Implemented |
| 6400.161(e)(1) | Per the ISP, intensive staffing is required because Individual 1 cannot name his medications or their doses, and staff must administer and maintain all medication. Per Staff 3, Individual 1 administers his own daily suppository. | To be considered able to self-administer medications, an individual shall do all of the following: Recognize and distinguish the individual's medication. | Individual 1 was assessed for medication self-administration upon admission. He is not able to self-administer at this time, so staff store, document, and administer all medications. One of Individual 1¿s daily medication is a nightly Mesalamine suppository for his Ulcerative Colitis. He has taken this medication for 7 years and 3 years ago, stated to his staff ¿I can do it¿ and successfully pushed the suppository into his own rectum. This has been the procedure since then for the past 3 years and was already in place when he transitioned to Nirvana Care on 7/17/24. Staff are physically right there with gloves and oversee the administration and documentation. This is not independent self-administration, but allows Individual 1 to push into his own rectum under close supervision. This physical action does not require him to name the medication and does not seem to warrant staff then having to insert the suppository for him. Individual 1 and his guardian would like to maintain the existing process his safety and dignity. |
05/05/2025
| Implemented |
| 6400.163(a) | Individual 1, SSD 1% cream in the primary med box was not labeled | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | The tube of this medication was placed into the Med box without the box with label. When the prescription is filled again, the tube and its box with label will be retained in the Med box. See attachment 3 photo. |
05/15/2025
| Implemented |
| 6400.165(c) | For Individual 1, the following medications were available in the home; however, were not listed on the MAR: IBU 400mg Tablet, Clonazepam 1mg | A prescription medication shall be administered as prescribed. | Directed Plan:
Immediate Update of Individual 1's MAR to include IBU 400mg and Clonazepam 1mg with correct dosages, instructions, and prescriber information. Verification that all medications present in the home match those listed on the MAR by House Manager/ Program Specialist. Medication administration refresher training conducted for all DSPs involved in Individual 1's care. |
| Not Implemented |
| 6400.166(a)(4) | For Individual 1, Clonazepam was found in the home and is not listed on the MAR. The ISP and Seizure Protocol note that Clonazepam is used for seizure rescue. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | This was a noted oversight given that Clonazepam is prescribed as a rescue medication only, and not a daily medication. Individual 1 has not needed this medication in years. However, it is prescribed and available in the home and should have been included on the MAR. This was corrected on 5/3/25. |
05/03/2025
| Implemented |
| 6400.166(a)(8) | For Individual 1, Mupirocin 2%, and Medihoney 80% Gel do not specify an area to apply the medications | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | Individual 1¿s mother and legal guardian is working with his healthcare providers to obtain corrected prescriptions that specify the affected/intended areas to apply the medication (wound care). |
05/15/2025
| Implemented |
| 6400.166(a)(11) | For Individual 1, the following medications did not include a diagnosis: Dairy Relief 3,000 Caplet, Deep Sea .65% Nose Spray, Hiya Kids Daily Multivitamin, Lansoprazole 30mg Cpdr, Melatonin 3mg Tablet, Mesalamine Supp 1000mg, Mupirocin 2%, and Medihoney 80% Gel
Diagnosis was not populated on the bottom of the MAR | 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. | Individual 1's mother and legal guardian is working with individual 1's healthcare provider to obtain corrected prescriptions that specify the affected/intended areas to apply the medication (wound care). |
05/15/2025
| Implemented |
| 6400.166(b) | Staff 1's name/signature was not on the MAR's | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | This is also a noted oversight. All Medication Certified staff must sign the front and back of Mar the first time they administer each month. Staff 1 has now signed the MAR. |
05/05/2025
| Implemented |
| 6400.169(d) | The following training records were not provided for Staff 1-5: Module Examination Summary Sheet of the Medications Training Manual, Signed and Dated Trainee Verification Forms, and a Practicum Summary. | A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. | Directed Plan:
Nirvana Care hired a consulting Med Admin Trainer. They only provided Med Admin Certificates, showing completion of required training elements, including the date completed. Nirvan will get from the Trainer the gloving and medication passes from the trainer. |
| Not Implemented |
| 6400.194(a) | For Individual 1, HRT documentation was not provided for the following restrictions that were observed and/or are noted in ISP/BSP: hands on techniques, cameras in/out home and in bedroom, bedroom door window, observing individual while showering. | If a restrictive procedure is used, the home shall use a human rights team. The home may use a county mental health and intellectual disability program human rights team that meets the requirements of this section. | Directed Plan:
The House Manager/Program Specialist will clarify documentation in Individual 1's ISP and BSP to explicitly state that no restrictive procedures are in use or authorized. The House Manager/ Program specialist will Correct or remove any language in plans that could be interpreted as referencing a restriction. The House Manager/ Program Specialist Update staff understanding through focused training on what constitutes a restriction and how to document supports vs. restrictions appropriately. |
| Not Implemented |
| 6400.195(c)(6) | For Individual 1, the Behavior Support Plan does not address Restrictive Procedures outlined in the ISP and observed in the home | The behavior support component of the individual plan shall include: Types of restrictive procedures that may be used and the circumstances under which the procedures may be used. | Directed Plan:
The House Manager/Program Specialist will clarify documentation in Individual 1's ISP and BSP to explicitly state that no restrictive procedures are in use or authorized. The House Manager/ Program specialist will Correct or remove any language in plans that could be interpreted as referencing a restriction. The House Manager/ Program Specialist Update staff understanding through focused training on what constitutes a restriction and how to document supports vs. restrictions appropriately. |
| Not Implemented |
| 6400.196(a) | Training records were not provided for any staff | A staff person who implements or manages a behavior support component of an individual plan shall be trained in the use of the specific techniques or procedures that are used. | Copies of BSP training were uploaded to SharePoint folders for ODP point person on 4/30/25. |
04/30/2025
| Implemented |
| 6400.207(4)(I) | For Individual 1, Lorazepam .5 label reads 'As needed for anxiety at mother's discretion.' There is no written protocol. | A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition. | Directed Plan:
Lorazepam was discontinued, but if at any time it is reinstated, or a new prescription is ordered Nirvana Care will put in place a protocol: Confirmed documentation by a physician or a medical practitioner of the individual's psychiatric diagnosis must be present in the individual's record.
2. Written instructions by a physician or medical practitioner listing the individual's specific symptoms of the psychiatric diagnosis that would warrant the use of a PRN psychotropic medication must be included in the physician's prescription of the medication.
3. Prescribed directions on the pharmacy label must include frequency (dose and allowable rate of recurrence of dosage) for administration of the PRN.
4. Authorization by the CEO or CEO's designee for each instance of administration of a PRN psychotropic medication must be documented in the applicable medication administration record.
5. Monitoring as indicated by a physician or medical professional and as directed on the pharmacy label of the actual response to medication each time a PRN is administered must be documented in the individual's record. |
| Not Implemented |
| 6400.208(a) | For Individual 1, physical hands-on techniques are being used in the home. | A physical restraint, defined as a manual method that restricts, immobilizes or reduces an individual's ability to move the individual's arms, legs, head or other body parts freely, may only be used in the case of an emergency to prevent an individual from immediate physical harm to the individual or others. | Directed Plan:
The House Manager/Program Specialist will clarify documentation in Individual 1's ISP and BSP to explicitly state that no restrictive procedures are in use or authorized. The House Manager/ Program specialist will Correct or remove any language in plans that could be interpreted as referencing a restriction. The House Manager/ Program Specialist Update staff understanding through focused training on what constitutes a restriction and how to document supports vs. restrictions appropriately. |
| Not Implemented |