| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.43(b)(1) | The Emergency Refill Process for prescriptions was not followed as written -- section 5.2.3 of the policy requires contact of healthcare facilities or emergency services to ensure individuals receive required medications. The incident report and communication with the agency did not indicate this step was taken. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | At Samaritans At Last, llc, we are committed to ensuring the safety and well-being of all individuals in our care. We acknowledge that the Emergency Refill Process for prescriptions, as outlined in Section 5.2.3 of our policy, was not followed correctly in a recent incident. Specifically, the required step of contacting healthcare facilities or emergency services to secure necessary medications was not documented.
To address this matter, we have taken immediate corrective actions, including staff retraining, policy reinforcement, and the implementation of additional oversight measures to ensure strict adherence to our procedures. Moving forward, we will continue to monitor compliance through routine audits and quality assurance reviews to prevent any recurrence of this issue.
We take this matter seriously and remain dedicated to upholding the highest standards of care for all individuals we serve. |
12/31/2024
| Implemented |
| 6400.62(a) | Poisonous material was located in Individual 1's bathroom, bedroom, hallway closet, and kitchen - individual 1's ISP indicates that all cleaners (regardless if they are considered poisonous) are be locked immediately after use. The bathroom contained mouthwash, toothpaste, various soaps and deodorant spray. The bedroom contained lotions and bottles of fragrances. The hallway closet contained general cleaning supplies. The Kitchen contained cleaning sprays, sanitizing wipes, dishwasher detergent pods, dish soap, and hand soap. | Poisonous materials shall be kept locked or made inaccessible to individuals. | "Our organization is committed to ensuring the health and safety of all individuals in our care. Upon identifying that poisonous materials were not properly secured in accordance with Individual 1¿s ISP, immediate corrective actions were taken. All hazardous materials have been locked away, and staff have been retrained on proper storage procedures. Moving forward, enhanced monitoring and compliance measures will be enforced to prevent future occurrences. We remain dedicated to upholding safety standards and providing a secure environment for all individuals we serve." |
12/13/2024
| Implemented |
| 6400.67(a) | Individual 1's bedroom closet door was broken and in need of repair. | Floors, walls, ceilings and other surfaces shall be in good repair. | In accordance with facility maintenance standards, the necessary repairs were completed on 12/30/2024 to ensure the door is in good working condition.
To prevent future occurrences, routine inspections will be conducted, and staff will be trained to promptly report any maintenance concerns. A maintenance log has been implemented to ensure timely resolution of repair needs. The House Manager/Maintenance Supervisor will oversee compliance maintenance standards.
This correction was completed on 12/30/2024, and the facility remains committed to maintaining a safe and well kept environment for all individuals. |
12/30/2024
| Implemented |
| 6400.72(a) | Individual 1's bedroom windows did not have screens installed and were open at the time of inspection. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | In accordance with facility maintenance standards, the necessary repairs were completed on 12/27/2024 to ensure the door is in good working condition.
To prevent future occurrences, routine inspections will be conducted, and staff will be trained to promptly report any maintenance concerns. A maintenance log has been implemented to ensure timely resolution of repair needs. The House Manager/Maintenance Supervisor will oversee compliance maintenance standards.
This correction was completed on 12/27/2024, and the facility remains committed to maintaining a safe and well kept environment for all individuals. |
12/31/2024
| Implemented |
| 6400.111(f) | The only fire extinguisher on site was not serviced annually and was last checked June 2023. The fire extinguisher was confirmed to be replaced the same day as the inspection. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | Samaritans At Last, llc has addressed this deficiency, and the fire extinguisher was replaced on the same day as the inspection. Moving forward, we will ensure all fire extinguishers are inspected and approved annually by a certified fire safety expert. A maintenance log will be kept, and a service contract will be established to prevent future lapses. |
12/31/2024
| Implemented |
| 6400.144 | Individual 1's PRN medications Loperamide 2mg capsules and Cough DM ER 30 mg/5mL suspension were not on site. An empty bottle of Cough DM ER 30 mg/5mL suspension was eventually located, but there was an insufficient quantity to provide a dose if needed by the individual. | 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.
| Immediate corrective actions have been implemented to ensure all prescribed medications are readily available at all times. We are committed to maintaining compliance with health service requirements and will continuously monitor our medication management processes to prevent future occurrences. |
12/31/2024
| Implemented |
| 6400.166(b) | The Medication Administration Record for Individual 1 contained inconsistencies that make it unable to determine if medication is being provided and documented reliably. Incident report #9538412 indicates that medications began to run out 12/13/2024 and did not begin being refilled and administered until 12/16/2024, resulting in several days of missing medications. The MAR indicated that all medicines were not administered beginning 8am 12/10/2024 through the 8pm dose 12/12/2024. There were also instances of different medicines given at the same time by different staff who, according to agency records, were not working at the time of administration. There were numerous blank fields signed, and some staff initials were misspelled on the MAR. The agency did not provide clarification of these inconsistencies when requested. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Immediate Action Taken:
The agency has conducted a review of the MAR for Individual 1 and documented all missing information to the extent possible.
Medications for Individual 1 have been refilled and are now being administered as prescribed.
A detailed internal investigation has been initiated to determine the root cause of the discrepancies.
Staff Training and Accountability:
All direct care staff responsible for medication administration have undergone a mandatory refresher training on proper MAR documentation procedures on 12/30/2024.
Staff will be retrained on the importance of recording medication administration in real-time and verifying the accuracy of the records.
A policy will be reinforced that only authorized personnel currently on shift may document medication administration.
Any staff found falsifying records will be subject to disciplinary action, up to and including termination.
Process and Documentation Improvement:
A new policy will be implemented requiring a second verification by a supervisor for all medication records at the end of each shift.
The MAR will be updated to include an electronic verification system to prevent unauthorized documentation by staff who are not scheduled to work.
All blank fields on the MAR must be completed with proper documentation or an explanation of missed doses.
Staff initials will be cross-checked with agency records to ensure accuracy. |
01/31/2025
| Implemented |
| 6400.167(a)(1) | According to the MAR provided, 14 different medications were not administered beginning with the 8am dose on 12/10/2024 and did not resume until the 8pm dose on 12/12/2024. | Medication errors include the following: Failure to administer a medication. | Immediate Correction:
Upon discovery of the missed doses, all affected medications were reviewed by the licensed nursing staff and consulting pharmacist to assess potential health risks to residents.
Physicians were notified immediately, and corrective actions, including necessary medical interventions, were implemented.
All medications were reconciled and resumed per physician orders as of 8:00 PM on 12/12/2024.
Root Cause Analysis:
A thorough investigation was conducted to determine the cause of the missed administrations.
Contributing factors such as communication with health care facilities and system failures were identified and improved upon.
Staff Education and Re-Training:
All licensed nursing staff and medication aides received mandatory retraining on proper medication administration procedures, including adherence to MAR protocols and timely documentation.
Staff were re-educated on the importance of verifying and double-checking MARs to prevent medication omissions.
Emergency phone numbers were updated to ensure reliability.
Competency evaluations were conducted for all medication administration personnel.
Policy and Procedure Review:
Medication administration policies were reviewed and updated to ensure clarity and accountability.
A new protocol was implemented requiring double verification of MAR entries at the start of each shift.
The use of an electronic medication administration record (eMAR) system is being evaluated to reduce manual errors.
Increased Monitoring and Oversight:
A Medication Administration Audit Program was implemented, with random weekly audits conducted for the next three months to ensure compliance.
Direct supervision of medication administration by nursing management will be conducted for all shifts for the next 30 days.
Any staff found in non-compliance will be subject to disciplinary action, including additional training or corrective measures.
Resident and Family Communication:
All affected residents and their families were notified of the medication error and corrective actions taken.
Ongoing monitoring and follow-up with residents to ensure there were no adverse effects from missed doses.
Compliance Monitoring and Continuous Improvement:
The Director of Nursing (DON) or designated supervisor will review medication administration logs weekly and report findings to the facility administrator.
Monthly compliance meetings will include medication administration performance reviews.
Findings and corrective measures will be submitted to the Quality Assurance and Performance Improvement (QAPI) committee for further evaluation and prevention strategies. |
12/31/2024
| Implemented |
| 6400.186 | There has not been adequate implementation of Individual 1's ISP, including recommended restrictive procedures. Individual 1's ISP indicates that all knives and silverware are to be locked immediately when not in use. The cabinet above the stove contained a chef's knife and several steak knives, the kitchen counter had numerous pieces of silverware sitting in the drainboard, and the silverware drawer contained a few pieces of silverware as well. All of these items were unsecured. The ISP also indicates Individual 1 will have limited access to a flip phone (30 minute intervals, to be locked away outside of these timeframes). Individual 1 had two smart phones in their lap during the entirety of the inspection (which was outside of the assigned timeframes) and was observed to have 2 additional smart phones in their bedroom. Their bedroom also contained at least 3 charging cables, of which access should be limited due to self-injurious and/or aggressive behaviors. | The home shall implement the individual plan, including revisions. | After the inspection, SAL has ensured that all knives and silverware are locked immediately when not in use; and the following were done.
-Conduct daily checks to confirm compliance with ISP storage requirements.
-Restrict Individual¿s access to smart phones per ISP guidelines, limiting usage to assigned timeframes.
-Remove or secure excess charging cables to reduce risk of self-injury or aggression.
-Train staff on the importance of ISP compliance and documentation.
-The staff was retrained on the recommended restrictive procedures. |
12/31/2024
| Implemented |