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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | According to page 22 of the Office of Developmental Programs' Incident Management Bulletin 00-21-02, Neglect is defined as the failure to obtain or provide the needed services and supports defined as necessary or otherwise required by law, regulation, policy, or plan. Neglect can occur when an agency fails to provide an individual with medication management, which is when a medication error occurs over more than one consecutive administration. The agency failed to provide Individual #1 with medication management by failing to administer the following medications as prescribed: Trazodone Tab 100mg at 8:00pm on 4/3/2026, 4/4/2026, 4/5/2026, 4/6/2026, 4/10/2026, 4/11/2026, 4/12/2026, and 4/13/2026; Inpen Blue Mis Nova/Fia at on 4/6/2026 at 6:00pm and 8:00pm, on 4/7/2026 at 4:00pm, 6:00pm, and 8:00pm, 4/8/2026 at 4:00pm, 6:00pm, and 8:00pm, 4/9/2026 at 4:00pm, 6:00pm, and 8:00pm, 4/10/2026 at 12:00pm, 4:00pm, 6:00pm, and 8:00pm, 4/11/2026 at 12:00pm, 4:00pm, 6:00pm, and 8:00pm, 4/12/2026 at 8:00am, 12:00pm, 4:00pm, 6:00pm, and 8:00pm, 4/13/2026 at 4:00pm, 6:00pm, and 8:00pm, 4/14/2026 at 4:00pm, 6:00pm, and 8:00pm, 4/15/2026 at 8:00am, 12:00pm, 4:00pm, 6:00pm, and 8:00pm, and 4/16/2026 at 4:00pm, 6:00pm, and 8:00pm; Lantus Solos Inj 100/mL at 8:00pm on 4/1/2026, 4/2/2026, 4/3/2026, 4/4/2026, 4/5/2026, 4/6/2026, 4/7/2026, 4/8/2026, 4/9/2026, 4/10/2026, 4/11/2026, 4/12/2026, 4/13/2026, 4/14/2026, 4/15/2026, and 4/16/2026; and Toujeo Max Inj 300/mL at 8:00pm on 4/1/2026, 4/2/2026, 4/3/2026, 4/4/2026, 4/5/2026, 4/6/2026, 4/7/2026, 4/8/2026, 4/9/2026, 4/10/2026, 4/11/2026, 4/12/2026, 4/13/2026, 4/14/2026, 4/15/2026, and 4/16/2026. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | On 4/18/2026 the CEO submitted an incident into the enterprise incident management system and initiated a certified investigation. |
04/18/2026
| Implemented |
| 6400.66 | On 4/17/2026 at 1:50pm, the staff office was observed without sufficient lighting as no operable light source was present in the room. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| On Saturday April 18, 2026, the CEO placed a lamp in the staff office. Providing adequate lighting is essential to ensure the individuals and staff members are able to safely evacuate in the event of an emergency and not risk being injured because of improper lighting. |
04/18/2026
| Implemented |
| 6400.77(b) | On 4/17/2026 at 1:44pm, the first aid kit did not contain tweezers. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | The director of operations added tweezers to the first aid kit on 4/17/2026. |
04/17/2026
| Implemented |
| 6400.141(b) | Individual #1's physical examination, completed on 12/10/2025, was not dated by a licensed physician, certified nurse practitioner, or licensed physician's assistant. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | The CEO submitted the physical exam form to the physician's office on 5/5/2026 to request that the date be added to the form. The CEO also updated the agency's physical examination form to include the date alongside the physician's signature to ensure that the physician signs and date. |
05/05/2026
| Implemented |
| 6400.141(c)(7) | Individual #1's most recent gynecological examination including a breast examination and a Pap test was completed on 12/9/2024. Individual #1 was seen by their gynecologist on 12/16/2025; however, the documentation from this appointment indicated that the purpose for the appointment was only to refill Individual #1's prescription birth control. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Individual #1 had a gynecological exam 11/7/2025. During transition of providers Brite Light Residential received documentation of the last gyne exam from 2024 and scheduled an appointment for 12/16/2025. During that appointment individual #1 was seen for birth control refill. When the CEO called to schedule a gynecological exam they were advised of the appointment that took place on 11/7/2025. Insurance will only authorize an exam once a year. |
04/29/2026
| Implemented |
| 6400.181(a) | Individual #1's assessment, completed by Program Specialist #1 on 12/19/2025, indicated that the individual can have up to 12 hours of alone time in the community; however, Individual #1's support plan, last updated 3/23/2026, stated "[Individual #1] can be in the community by [themself] for up to 6 hours if it is a known area. [Individual #1] will check in with staff on a regular basis and be back home at 8:00pm for medications. [Individual #1] would need staff assistance - within eyesight - to be in an unknown area···[Individual #1] will overstep [their] boundaries and go out past [their] allotted free time. If [Individual #1] does not return to the site at 8:00pm, please call [their] phone three times and document that you called [their] phone three times. If you don't hear back by 8:30pm please submit incident report for missing individual." Individual #1's assessment was not updated to reflect the change in need.
Individual #1's assessment, completed by Program Specialist #1 on 12/19/2025, indicated "Yes" that the individual can self-administer their medications; however, Individual #1's support plan, last updated 3/23/2026, stated "[Individual #1] is not able to administer [their] medication." Conversations with agency staff revealed that Individual #1 stopped self-administering their medications on 3/27/2026. Individual #1's assessment was not updated to reflect the change in need. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | On 4/23/2026 the program specialist updated the individual assessment form to reflect the correct amount of time individual #1 is allowed out in the community which is 6 hours at a time. Also, the area pertaining to administering medications was updated to reflect that individual #1 is not administering their medications at this time. |
04/23/2026
| Implemented |
| 6400.214(b) | On 4/17/2026 at approximately 11:30am, Individual #1's support plan that was available on-site in the residential home had last been updated on 6/27/2025; however, the version that was available on-line on the Home and Community Services Information System was last updated 3/23/2026. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| The CEO printed the most recent ISP of individual #1 and trained all staff on the new plan on 4/22/26. The most recent plan was filed with the individual records. |
04/22/2026
| Implemented |
| 6400.18(b)(2) | On 4/17/2026 at 4:00pm, the agency was made aware of the following medication errors where Individual #1 failed to receive their prescribed medications: Sertraline Tab 100mg at 8:00am on 4/10/2026 and 4/15/2026; Venlafaxine Cap 75mg ER at 8:00am on 4/10/2026, 4/13/2026, and 4/15/2026; Pantoprazole Tab 40mg at 8:00am on 4/10/2026 and 4/15/2026; Ziprasidone Cap 20mg at 8:00am on 4/10/2026 and 4/15/2026; Trazodone Tab 100mg at 8:00pm on 4/3/2026, 4/4/2026, 4/5/2026, 4/6/2026, 4/10/2026, 4/11/2026, 4/12/2026, and 4/13/2026; Polyethylene Glycol Pow 3350 at 8:00am on 4/10/2026 and 4/15/2026; Inpen Blue Mis Nova/Fia at 8:00am on 4/12/2026, 4/15/2026, and 4/17/2026, at 12:00pm on 4/10/2026, 4/11/2026, 4/12/2026, and 4/15/2026, at 4:00pm on 4/7/2026, 4/8/2026, 4/9/2026, 4/10/2026, 4/11/2026, 4/12/2026, 4/13/2026, 4/14/2026, 4/15/2026, and 4/16/2026, at 6:00pm on 4/6/2026, 4/7/2026, 4/8/2026, 4/9/2026, 4/10/2026, 4/11/2026, 4/12/2026, 4/13/2026, 4/14/2026, 4/15/2026, and 4/16/2026, and at 8:00pm on 4/6/2026, 4/7/2026, 4/8/2026, 4/9/2026, 4/10/2026, 4/11/2026, 4/12/2026, 4/13/2026, 4/14/2026, 4/15/2026, and 4/16/2026; Lantus Solos Inj 100/mL at 8:00pm on 4/1/2026, 4/2/2026, 4/3/2026, 4/4/2026, 4/5/2026, 4/6/2026, 4/7/2026, 4/8/2026, 4/9/2026, 4/10/2026, 4/11/2026, 4/12/2026, 4/13/2026, 4/14/2026, 4/15/2026, and 4/16/2026; and Toujeo Max Inj 300/mL at 8:00pm on 4/1/2026, 4/2/2026, 4/3/2026, 4/4/2026, 4/5/2026, 4/6/2026, 4/7/2026, 4/8/2026, 4/9/2026, 4/10/2026, 4/11/2026, 4/12/2026, 4/13/2026, 4/14/2026, 4/15/2026, and 4/16/2026. Additionally, Individual #1 is prescribed Zepbound Inj 5/0.5mL with instructions to "Inject 0.5mL into skin every 7 days for weight loss." As of 4/17/2026, this medication had not been administered during the month of April. Individual #1's April 2026 medication administration record did not indicate which day of the week the medication was to be administered; however, a minimum of one dose had been missed between 4/1/2026 and 4/17/2026. As of 4/24/2026 at 10:30am, these medication errors had not been reported through the Department's information management system. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | The CEO entered the incident into the enterprise incident management system on 4/25/2026. |
04/25/2026
| Implemented |
| 6400.45(c) | Individual #1's individual support plan, last updated 3/23/2026, documents the individual's supervision as "[The individual] can be in her apartment alone up to 15 minutes and there is staff on site at all times. [The individual] can be in the community by herself for up to 6 hours if it is a known area. [The individual] will check in staff on a regular basis and be back home at 8:00 PM for medications. [The individual] would need staff assistance-within eyesight- to be in an unknown area." On 1/29/2026 Individual #1 disclosed to staff that she wanted to stay with a friend she met at the mall. The "friend" was an unknown person to staff. The individual stayed at a friend's house 1/29/2026 and 1/30/2026. The individual returned home on 1/31/2026. The agency reported missing individual incident #9778466 in Department's Enterprise Incident Management system. Witness statements included in the agency's investigation documented "On 1/29/2026 when staff arrived on site, {Individual #1] wasn't home" and "When staff arrived on 1/30/2026, [Individual #1] wasn't home. | An individual may be left unsupervised for specified periods of time if the absence of direct supervision is consistent with the individual's assessment and is part of the individual plan, as an outcome which requires the achievement of a higher level of independence. | Brite Light operates 24 hour facilities and there is staff onsite at all times. Brite Light will continue to provide staffing for the individuals we serve and adhere to their needs that are outlined in their individual support plan. |
04/17/2026
| Implemented |
| 6400.163(d) | On 4/17/2026 at 1:44pm, the first aid kit was observed with two single-dose packets of Tylenol for Adults Extra Strength 500mg Caplets. The first aid kit was unlocked and accessible in the closet adjacent to the front door of the apartment. Individual #1's support plan, last updated 3/23/2026, stated that "[Individual #1] is not able to administer [their] medication." | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | On 4/17/2026 the director of operations removed the two single dose packets of Tylenol from the first aid kit. |
04/17/2026
| Implemented |
| 6400.163(h) | Individual #1 was previously prescribed Hydroxyz HCL Tab 50mg with instructions to "take 1 tablet by mouth twice daily as needed." This prescription was discontinued at Individual #1's psychiatric medication review on 12/16/2025 when the medication was prescribed as a standing order. A blister pack containing 11 pills had not been removed from the residence and destroyed in a safe manner. Individual #1 was previously prescribed Hydroxyz HCL Tab 50mg with instructions to "take 1 tablet by mouth twice daily for bipolar disorder." This prescription was discontinued at Individual #1's psychiatric medication review on 4/8/2026 when the frequency of the medication was upped to three times daily. The morning blister pack containing 3 pills and the bedtime blister pack containing 3 pills had not been removed from the residence and destroyed in a safe manner. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | On 4/20/2026 The director of operations disposed of the blister pack containing 11 pills of hydroxyzine and the blister pack containing 3 pills and disposed of them only leaving the current prescribed medications. |
04/20/2026
| Implemented |
| 6400.165(b) | Individual #1 was previously prescribed Hydroxyz HCL Tab 50mg with instructions to "take 1 tablet by mouth twice daily as needed." This prescription was discontinued at Individual #1's psychiatric medication review on 12/16/2025 when the medication was prescribed as a standing order; however, this medication had not been discontinued from Individual #1's April 2026 medication administration record. | A prescription order shall be kept current. | A prescription order shall be kept current. The Hydroxzine HCL tablet 50mg was omitted from the medication administration record. On 4/20/26 the CEO updated the record to include all the current medications. |
04/20/2026
| Implemented |
| 6400.166(a)(4) | Individual #1 is prescribed Aripiprazole Tab 5mg with instructions to "take 1 tablet by mouth every morning for cholesterol." Individual #1's April 2026 medication administration record did not include the name of this medication. Individual #1 was prescribed this medication on 4/8/2026; however, it was omitted entirely from their medication administration record. Individual #1 is prescribed Hydroxyz HCL Tab 50mg with instructions to "Take 1 tablet by mouth three times daily for bipolar disorder." Individual #1's April 2026 medication administration record did not include the name of this medication. Individual #1 was prescribed this medication on 4/8/2026; however, it was omitted entirely from their medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | On 4/20/2026 CEO updated the medication record to include all components of the medication label including the name of the medication, strength, the time, and the route for all current medications for individual #1. |
04/20/2026
| Implemented |
| 6400.166(a)(5) | Individual #1 is prescribed Aripiprazole Tab 5mg with instructions to "take 1 tablet by mouth every morning for cholesterol." Individual #1's April 2026 medication administration record did not include the strength of this medication. Individual #1 was prescribed this medication on 4/8/2026; however, it was omitted entirely from their medication administration record. Individual #1 is prescribed Hydroxyz HCL Tab 50mg with instructions to "Take 1 tablet by mouth three times daily for bipolar disorder." Individual #1's April 2026 medication administration record did not include the strength of this medication. Individual #1 was prescribed this medication on 4/8/2026; however, it was omitted entirely from their medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | On 4/20/2026 The CEO updated the medication record to include all components of the medication label including the name of the medication, strength, the time, and the route for all current medications for individual #1. |
04/20/2026
| Implemented |
| 6400.166(a)(6) | Individual #1 is prescribed Aripiprazole Tab 5mg with instructions to "take 1 tablet by mouth every morning for cholesterol." Individual #1's April 2026 medication administration record did not include the dosage form of this medication. Individual #1 was prescribed this medication on 4/8/2026; however, it was omitted entirely from their medication administration record. Individual #1 is prescribed Hydroxyz HCL Tab 50mg with instructions to "Take 1 tablet by mouth three times daily for bipolar disorder." Individual #1's April 2026 medication administration record did not include the dosage form of this medication. Individual #1 was prescribed this medication on 4/8/2026; however, it was omitted entirely from their medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | On 4/20/2026 The CEO updated the medication record to include all components of the medication label including the name of the medication, strength, the time, and the route for all current medications for individual #1. |
04/20/2026
| Implemented |
| 6400.166(a)(7) | Individual #1 is prescribed Aripiprazole Tab 5mg with instructions to "take 1 tablet by mouth every morning for cholesterol." Individual #1's April 2026 medication administration record did not include the prescribed dose of this medication. Individual #1 was prescribed this medication on 4/8/2026; however, it was omitted entirely from their medication administration record. Individual #1 is prescribed Hydroxyz HCL Tab 50mg with instructions to "Take 1 tablet by mouth three times daily for bipolar disorder." Individual #1's April 2026 medication administration record did not include the prescribed dose of this medication. Individual #1 was prescribed this medication on 4/8/2026; however, it was omitted entirely from their medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | On 4/20/2026 The CEO updated the medication record to include all components of the medication label including the name of the medication, strength, the time, frequency and the route for all current medications for individual #1. |
04/20/2026
| Implemented |
| 6400.166(a)(8) | Individual #1 is prescribed Aripiprazole Tab 5mg with instructions to "take 1 tablet by mouth every morning for cholesterol." Individual #1's April 2026 medication administration record did not include the route of administration for this medication. Individual #1 was prescribed this medication on 4/8/2026; however, it was omitted entirely from their medication administration record. Individual #1 is prescribed Hydroxyz HCL Tab 50mg with instructions to "Take 1 tablet by mouth three times daily for bipolar disorder." Individual #1's April 2026 medication administration record did not include the route of administration for this medication. Individual #1 was prescribed this medication on 4/8/2026; however, it was omitted entirely from their medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | On 04/20/2026 The CEO updated the medication record to include all components of the medication label including the name of the medication, strength, the time, frequency and the route for all current medications for individual #1. |
04/20/2026
| Implemented |
| 6400.166(a)(9) | Individual #1 is prescribed Aripiprazole Tab 5mg with instructions to "take 1 tablet by mouth every morning for cholesterol." Individual #1's April 2026 medication administration record did not include the frequency of administration for this medication. Individual #1 was prescribed this medication on 4/8/2026; however, it was omitted entirely from their medication administration record. Individual #1 is prescribed Hydroxyz HCL Tab 50mg with instructions to "Take 1 tablet by mouth three times daily for bipolar disorder." Individual #1's April 2026 medication administration record did not include the frequency of administration for this medication. Individual #1 was prescribed this medication on 4/8/2026; however, it was omitted entirely from their medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | On 04/20/2026 The CEO updated the medication record to include all components of the medication label including the name of the medication, strength, the time, frequency, diagnosis and the route for all current medications for individual #1. |
04/20/2026
| Implemented |
| 6400.166(a)(10) | Individual #1 is prescribed Aripiprazole Tab 5mg with instructions to "take 1 tablet by mouth every morning for cholesterol." Individual #1's April 2026 medication administration record did not include the administration time for this medication. Individual #1 was prescribed this medication on 4/8/2026; however, it was omitted entirely from their medication administration record. Individual #1 is prescribed Hydroxyz HCL Tab 50mg with instructions to "Take 1 tablet by mouth three times daily for bipolar disorder." Individual #1's April 2026 medication administration record did not include the administration times for this medication. Individual #1 was prescribed this medication on 4/8/2026; however, it was omitted entirely from their medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | On 04/20/2026 The CEO updated the medication record to include all components of the medication label including the name of the medication, strength, the time, frequency, diagnosis and the route for all current medications for individual #1. |
04/20/2026
| Implemented |
| 6400.166(a)(11) | Individual #1 is prescribed Aripiprazole Tab 5mg with instructions to "take 1 tablet by mouth every morning for cholesterol." Individual #1's April 2026 medication administration record did not include the diagnosis or purpose for prescribing this medication. Individual #1 was prescribed this medication on 4/8/2026; however, it was omitted entirely from their medication administration record. Individual #1 is prescribed Hydroxyz HCL Tab 50mg with instructions to "Take 1 tablet by mouth three times daily for bipolar disorder." Individual #1's April 2026 medication administration record did not include the diagnosis or purpose for prescribing this medication. Individual #1 was prescribed this medication on 4/8/2026; however, it was omitted entirely from their medication administration record. Individual #1 is prescribed Sertraline Tab 100mg with instructions to "take 2 tablets (200mg) by mouth once daily." Individual #1's April 2026 medication administration record did not include the diagnosis or purpose for prescribing this medication. Individual #1 is prescribed Venlafaxine Cap 75mg ER with instruction to "take 1 capsule by mouth once daily." Individual #1's April 2026 medication administration record did not include the diagnosis or purpose for prescribing this medication. Individual #1 is prescribed Trazodone Tab 100mg with instructions to "take 1 tablet by mouth at bedtime." Individual #1's April 2026 medication administration record did not include the diagnosis or purpose for prescribing this medication. Individual #1 is prescribed Calc Antacid Chew 500mg with instruction to "chew 2 tablets (1,000 mg) by mouth twice daily." Individual #1's April 2026 medication administration record did not include the diagnosis or purpose for prescribing this medication. | 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. | On 04/20/2026 The CEO updated the medication record to include all components of the medication label including the name of the medication, strength, the time, frequency, diagnosis and the route for all current medications for individual #1. |
04/20/2026
| Implemented |
| 6400.166(a)(12) | Individual #1 is prescribed Aripiprazole Tab 5mg with instructions to "take 1 tablet by mouth every morning for cholesterol." Individual #1's April 2026 medication administration record did not include the date and times the medication had been administered. Individual #1 was prescribed this medication on 4/8/2026; however, it was omitted entirely from their medication administration record. The blister pack for this medication was observed with 4 pills missing from the card; therefore, it can be assumed the medication had been administered since it was prescribed on 4/8/2026. Individual #1 is prescribed Hydroxyz HCL Tab 50mg with instructions to "Take 1 tablet by mouth three times daily for bipolar disorder." Individual #1's April 2026 medication administration record did not include the name of this medication. Individual #1 was prescribed this medication on 4/8/2026; however, it was omitted entirely from their medication administration record. The afternoon blister pack for this medication was observed with 2 pills missing from the card; therefore, it can be assumed the medication had been administered since it was prescribed on 4/8/2026. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration. | The CEO updated the medication record to include all components of the medication label including the name of the medication, strength, the time, frequency, diagnosis and the route for all current medications for individual #1. |
04/20/2026
| Implemented |
| 6400.166(a)(13) | Individual #1 is prescribed Aripiprazole Tab 5mg with instructions to "take 1 tablet by mouth every morning for cholesterol." Individual #1's April 2026 medication administration record did not include the name and initials of the person administering the medication. Individual #1 was prescribed this medication on 4/8/2026; however, it was omitted entirely from their medication administration record. The blister pack for this medication was observed with 4 pills missing from the card; therefore, it can be assumed the medication had been administered since it was prescribed on 4/8/2026. Individual #1 is prescribed Hydroxyz HCL Tab 50mg with instructions to "Take 1 tablet by mouth three times daily for bipolar disorder." Individual #1's April 2026 medication administration record did not include the name and initials of the person administering the medication. Individual #1 was prescribed this medication on 4/8/2026; however, it was omitted entirely from their medication administration record. The afternoon blister pack for this medication was observed with 2 pills missing from the card; therefore, it can be assumed the medication had been administered since it was prescribed on 4/8/2026. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | The CEO created a new medication administration course for the staff to be retrained in. The staff will have the course completed by Friday May 8, 2026. |
05/08/2026
| Implemented |
| 6400.167(a)(1) | On 4/17/2026 at approximately 12:30pm, it was observed that agency staff failed to administer the following medications to individual #1: Sertraline Tab 100mg at 8:00am on 4/10/2026 and 4/15/2026; Venlafaxine Cap 75mg ER at 8:00am on 4/10/2026, 4/13/2026, and 4/15/2026; Pantoprazole Tab 40mg at 8:00am on 4/10/2026 and 4/15/2026; Ziprasidone Cap 20mg at 8:00am on 4/10/2026 and 4/15/2026; Trazodone Tab 100mg at 8:00pm on 4/3/2026, 4/4/2026, 4/5/2026, 4/6/2026, 4/10/2026, 4/11/2026, 4/12/2026, and 4/13/2026; Polyethylene Glycol Pow 3350 at 8:00am on 4/10/2026 and 4/15/2026; Inpen Blue Mis Nova/Fia at 8:00am on 4/12/2026, 4/15/2026, and 4/17/2026, at 12:00pm on 4/10/2026, 4/11/2026, 4/12/2026, and 4/15/2026, at 4:00pm on 4/7/2026, 4/8/2026, 4/9/2026, 4/10/2026, 4/11/2026, 4/12/2026, 4/13/2026, 4/14/2026, 4/15/2026, and 4/16/2026, at 6:00pm on 4/6/2026, 4/7/2026, 4/8/2026, 4/9/2026, 4/10/2026, 4/11/2026, 4/12/2026, 4/13/2026, 4/14/2026, 4/15/2026, and 4/16/2026, and at 8:00pm on 4/6/2026, 4/7/2026, 4/8/2026, 4/9/2026, 4/10/2026, 4/11/2026, 4/12/2026, 4/13/2026, 4/14/2026, 4/15/2026, and 4/16/2026; Lantus Solos Inj 100/mL at 8:00pm on 4/1/2026, 4/2/2026, 4/3/2026, 4/4/2026, 4/5/2026, 4/6/2026, 4/7/2026, 4/8/2026, 4/9/2026, 4/10/2026, 4/11/2026, 4/12/2026, 4/13/2026, 4/14/2026, 4/15/2026, and 4/16/2026; and Toujeo Max Inj 300/mL at 8:00pm on 4/1/2026, 4/2/2026, 4/3/2026, 4/4/2026, 4/5/2026, 4/6/2026, 4/7/2026, 4/8/2026, 4/9/2026, 4/10/2026, 4/11/2026, 4/12/2026, 4/13/2026, 4/14/2026, 4/15/2026, and 4/16/2026. Additionally, Individual #1 is prescribed Zepbound Inj 5/0.5mL with instructions to "Inject 0.5mL into skin every 7 days for weight loss." As of 4/17/2026, this medication had not been administered during the month of April. Individual #1's April 2026 medication administration record did not indicate which day of the week the medication was to be administered; however, a minimum of one dose had been missed between 4/1/2026 and 4/17/2026. | Medication errors include the following: Failure to administer a medication. | The CEO created a new medication administration course for the staff to be retrained in. The staff will have the course completed by Friday May 8, 2026. |
05/08/2026
| Implemented |
| 6400.181(f) | Individual #1's assessment, completed by Program Specialist #1 on 12/19/2025, was not sent to the individual's plan team in preparation for the annual plan meeting that was held on 2/9/2026. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The importance of the annual assessment is that it will likely change over time and when it does the information should be relayed to the team. On 10/16/25 individual #1 received an annual assessment and a copy was not forwarded to the support team in preparation for the annual plan meeting. The program specialist forwarded the assessment to the support team on 4/30/26. |
04/30/2026
| Implemented |
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