| 6400.52(a)(2) | Staff #1 had 8.75 hours of training completed within the last training year. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct supervisors of direct service workers. | The HR department failed to ensure staff person #1 had completed 24 hours of training for the calendar year.
On 7/2/25, the HR department complete audit of employee files to ensure all staff had completed the required 24 hours of training for both new hires and existing staff members. All staff were re-educated by the HR department on the agency's mandatory trainin requirements. |
07/02/2025
| Implemented |
| 6400.163(h) | Individual #1 is prescribed PRN Lorazepam to be taken prior to appointments, however this medication expired on 4/1/25. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Support staff failed to take notice of the expiration date on the bottle of Lorazepam during daily counts of the medication.
On 7/2/25, the CEO removed the expire bottle of individual #1 prn Lorazepam from the medication box and contact the PCP for a refill of the medication. On 7/28/25, individual #1 doctor discontinued the use of the prn Lorazepam.
Support staff was reeducate on reminders to check the expiration dates on all medications as a part of everyday work practices. |
07/02/2025
| Implemented |