| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.144 | On 6/30/25 Individual #1 was treated at the emergency department due to loss of consciousness. Discharge directions noted that they should "follow up PCP within 48 hours." Individual #1 was seen by the primary care physician (PCP) on 7/3/25. The PCP notations from the 7/3/25 visit indicates the following: "lab work, X-ray ribs, ab ultrasound STAT." The recommended STAT testing was not completed until 7/24/25 for the ultrasound, 7/30/25 for the labwork and 8/6/25 for the x-ray. The testing was not completed within the specified timeframe of STAT or immediately as directed.
Individual #1 is prescribed Antacid/antigas max liquid to be administered as "Take 20ML by mouth every 8 hours as needed for indigestion or heartburn." When reviewed at the home there was no 20ml measuring device available. The correct measuring device must be in the home so that the medication can be administered as prescribed when needed. | 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.
| Individual #1's outstanding testing orders were reviewed, and no additional STAT orders are pending.
Staff involved were retrained immediately on the meaning, urgency, and required timeframes for STAT and follow-up medical orders.
A 30mL oral cup (metric only, clearly marked) was placed with the medication immediately.
Staff working in the home were re-educated same day on using metric oral cups and documenting scheduled & PRN administration per MAR.
Medication storage was updated so the cup is stored together with the PRN bottle in a labeled zip pouch. |
01/28/2026
| Implemented |
| 6400.165(c) | Individual #1 is prescribed Qualifiber Powder "Mix 2 teaspoonful of powder in 8 oz of water and drink every morning to prevent constipation. The 5.4oz 38 dose bottle in use at the time of inspection was dated as filled on 11/25/25. There was approximately one inch of powder remaining in the container.
Estimating the start date of the bottle to be 12/1/25 the bottle in use at the time of inspection would have been empty by 1/7/26. The medication was not administered as prescribed.
Individual #1 is prescribed Fluticasone nasal spray as "Inhale 1 spray in each nostril once daily for allergies." The nearly full bottle in use at the time of inspection was dated as filled on 7/9/25 and contained 120 metered sprays according to manufacturer packaging. 120 sprays are a 60 day supply if administered as prescribed. The medication in use at the time of inspection would have been gone and needed replacement by approximately 9/15/25.
Individual #1 is prescribed Norg-ethin estra 0.25-0.035mg as "Take one tablet by mouth once every day for contraception." The medication is packed by the days of the week and with directions of "Start here" for Week 2 on the packaging. When reviewed on Wednesday, 1/28/26, the pills had not been given according to the package directions. For week 1 the Tuesday pill remained in the blister pack. For Week 2 the week with the direction to "Start Here" was full with the exception of the Sunday pill which was missing from the middle of the row. For full effectiveness the pills must be administered in the order packaged. The medication was not administered as prescribed. | A prescription medication shall be administered as prescribed. | 1) The current Qualifiber bottle and Fluticasone nasal spray were immediately reviewed, and new replacement bottles were obtained and dated upon opening.
The Health Services Coordinator (HSC) has historically ordered two bottles of Qualifiber (a 60day supply), as well as two bottles of Fluticasone nasal spray, to ensure a backup was available as the first bottle became low. Both bottles typically carried the same refill date on the pharmacy label. This practice will be revised to prevent confusion and ensure accurate supply tracking.
Vincent House staff responsible for medication administration were reeducated on the requirement to administer Qualifiber daily and the Fluticasone nasal spray as prescribed, and to document each dose appropriately.
2) The current contraceptive blister pack was reviewed immediately, and staff were instructed to resume administration following the sequence indicated on the packaging.
All Vincent house Staff responsible for Individual #1's medication administration were re-educated the same day on:
The importance of administering contraceptive pills in order, verifying the correct pill for the correct day, and documenting each dose in real time. |
02/06/2026
| Implemented |
| 6400.195(a) | Individual #1 has a restrictive procedure in place for the locking of sharps that was being implemented at time of inspection on 1/28/26. The plan is dated as written on 10/30/25 and approved on 12/19/25. The 12/19/25 documentation of approval provided was only a chairperson's signature without verification of qualifications and no other signatures approving. Documentation did not illustrate that the plan was approved by an appropriate Human Riths Team (HRT) to indicate that the plan was approved by an appropriate Human Rights Team as required. | For each individual for whom a restrictive procedure may be used, the individual plan shall include a component addressing behavior support that is reviewed and approved by the human rights team in § 6400.194 (relating to human rights team), prior to use of a restrictive procedures. | UCCH contracts behavior support services through KenCrest. At the time of the inspection, KenCrest provided only the documentation containing the chairperson's signature, indicating approval of the restrictive procedure, but did not include the full Human Rights Team (HRT) signature sheet. The Program Manager immediately contacted KenCrest to request the complete documentation. The full HRT signature sheet, including all team members, was provided the following week on 2/5/2026. |
02/05/2026
| Implemented |