| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(a) | At 11:25AM on 9/18/2024, the screens in Individual #2's bedroom were approximately one and a half inches shorter than the windows and did not securely fit leaving space for insects to enter the home. At 11:28AM on 9/18/2024, the screens in the first and third windows in Individual #1's bedroom were approximately one and a half inches shorter than the windows and did not securely fit leaving space for insects to enter the home | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Contracted Handyman and new screens were installed to ensure no small gap was present. 10/1/2024. |
10/01/2024
| Implemented |
| 6400.101 | At 11:13AM on 9/18/2024, there was a vertical metal latch lock with a pull out latch at the top and the bottom installed on the left side of the sliding glass door in the basement leading to the back of the home. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The Program Specialist and Operations Manager participated in a Therap training that taught how to utilize the Pharmacy interface for adding medications to the MAR and to also ensure the diagnosis is located on the MAR.
The Operations Manager added the Medication Deliveries/ Out of Medications/ Disposing Medications protocol to ensure the MAR/Label match exactly. (9/24/2024)
The Program Manager, Program Specialist, and Residential Supervisors were trained on this new protocol. (9/30-10/3/2024)
Medication Deliveries: Medications are delivered to the main office per a schedule set by PDC pharmacy. The following protocol must be followed to ensure compliance with the regulations 6400.166:
1. Every 3rd Thursday of the month, Supervisors are to ensure that medication lock boxes are present at the office (after 12pm med pass).
2. All medications must be counted to ensure the cycle count is accurate. Supervisors are to utilize a printed MAR and the Packaging slip to complete this count.
3. When reviewing the delivered medications, the following items must be reviewed to ensure the Medication Label and MAR match exactly:
a. Individual Name b. Name of the Prescriber c. Name of Medication
d. Strength of Medication e. Dosage form f. Dose of medication
g. Route of Administration h. Frequency of administration i. Diagnosis or purpose for the medication, including pro re nata J. Brand Name k. time of administration
4. Any incorrect information found on the MAR must be submitted to the Program Specialist for corrections. These corrections must be completed on the same day.
5. This process must be completed every 3rd Thursday at the Program Meeting.
6. Supervisors will sign off on the Medications form monthly verifying that they have completed the steps above.
7. Medications will be delivered back to the homes before the next med pass at 4pm.
8. Ozempic and any subcutaneous medications will be kept at the office for safekeeping and proper administration.
9. Medication Errors are required to be submitted in EIM within 72 hours and reported to the Individuals designee.
The Program Manager, Program Specialist, and Residential Supervisors were trained on this new protocol. (9/30-10/3/2024) |
09/27/2024
| Implemented |
| 6400.18(b)(2) | Individual #1 is prescribed Topiramate Tab 100MG with instructions to, "Take 1 tablet by mouth twice a day for mood stabilization." This medication was not administered to Individual #1 as prescribed from 8:00PM on 9/1/2024 through 8:00AM on 9/4/2024 with the reason listed as "no medication." Individual #1 is prescribed Olanzapine Tab 20MG with instructions to, "Take 1 tablet by mouth every night at bedtime for mood stabilization." This medication was not administered to Individual #1 as prescribed at 8:00PM from 9/1/2024 through 9/4/2024 with the reason listed as, "Medication not present." The provider did not report these medication errors to Enterprise Incident Management, the Department's incident 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 Certified Investigator submitted the Medication error to EIM under #9492275. (9/28/2024)
The current Certified Investigator Policy was reviewed with the Program Manager for proper filing requirements. (9/24/2024)
The Operations Manager added the Medication Deliveries/ Out of Medications/ Disposing Medications protocol to reflect the proper reporting procedures for medications errors.
The Program Manager, Program Specialist, and Residential Supervisors were trained on this new protocol. (9/30-10/3/2024)
Medication Deliveries: Medications are delivered to the main office per a schedule set by PDC pharmacy. The following protocol must be followed to ensure compliance with the regulations 6400.166:
1. Every 3rd Thursday of the month, Supervisors are to ensure that medication lock boxes are present at the office (after 12pm med pass).
2. All medications must be counted to ensure the cycle count is accurate. Supervisors are to utilize a printed MAR and the Packaging slip to complete this count.
3. When reviewing the delivered medications, the following items must be reviewed to ensure the Medication Label and MAR match exactly:
a. Individual Name b. Name of the Prescriber c. Name of Medication
d. Strength of Medication e. Dosage form f. Dose of medication
g. Route of Administration h. Frequency of administration i. Diagnosis or purpose for the medication, including pro re nata J. Brand Name k. time of administration
4. Any incorrect information found on the MAR must be submitted to the Program Specialist for corrections. These corrections must be completed on the same day.
5. This process must be completed every 3rd Thursday at the Program Meeting.
6. Supervisors will sign off on the Medications form monthly verifying that they have completed the steps above.
7. Medications will be delivered back to the homes before the next med pass at 4pm.
8. Ozempic and any subcutaneous medications will be kept at the office for safekeeping and proper administration.
9. Medication Errors are required to be submitted in EIM within 72 hours and reported to the Individuals designee. |
09/27/2024
| Implemented |
| 6400.166(a)(11) | Individual #1 is prescribed Olanzapine for "Mood Stabilization." Individual #1's September 2024 Medication Administration Record documents the diagnosis as, "Schizophrenia." Individual #1 is prescribed Topiramate for, "Mood Stabilization." Individual #1's September 2024 Medication Administration Record documents the diagnosis as, "Epilepsy." | 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. | The Program Specialist and Operations Manager participated in a Therap training that taught how to utilize the Pharmacy interface for adding medications to the MAR and to also ensure the diagnosis is located on the MAR.
The Operations Manager added the Medication Deliveries/ Out of Medications/ Disposing Medications protocol to ensure the MAR/Label match exactly. (9/24/2024)
The Program Manager, Program Specialist, and Residential Supervisors were trained on this new protocol. (9/30-10/3/2024)
Medication Deliveries: Medications are delivered to the main office per a schedule set by PDC pharmacy. The following protocol must be followed to ensure compliance with the regulations 6400.166:
1. Every 3rd Thursday of the month, Supervisors are to ensure that medication lock boxes are present at the office (after 12pm med pass).
2. All medications must be counted to ensure the cycle count is accurate. Supervisors are to utilize a printed MAR and the Packaging slip to complete this count.
3. When reviewing the delivered medications, the following items must be reviewed to ensure the Medication Label and MAR match exactly:
a. Individual Name b. Name of the Prescriber c. Name of Medication
d. Strength of Medication e. Dosage form f. Dose of medication
g. Route of Administration h. Frequency of administration i. Diagnosis or purpose for the medication, including pro re nata J. Brand Name k. time of administration
4. Any incorrect information found on the MAR must be submitted to the Program Specialist for corrections. These corrections must be completed on the same day.
5. This process must be completed every 3rd Thursday at the Program Meeting.
6. Supervisors will sign off on the Medications form monthly verifying that they have completed the steps above.
7. Medications will be delivered back to the homes before the next med pass at 4pm.
8. Ozempic and any subcutaneous medications will be kept at the office for safekeeping and proper administration.
9. Medication Errors are required to be submitted in EIM within 72 hours and reported to the Individuals designee.
The Program Manager, Program Specialist, and Residential Supervisors were trained on this new protocol. (9/30-10/3/2024) |
09/27/2024
| Implemented |
| 6400.167(a)(1) | Individual #1 is prescribed Topiramate Tab 100MG with instructions to, "Take 1 tablet by mouth twice a day for mood stabilization." This medication was not administered to Individual #1 as prescribed from 8:00PM on 9/1/2024 through 8:00AM on 9/4/2024 with the reason listed as "no medication." Individual #1 is prescribed Olanzapine Tab 20MG with instructions to, "Take 1 tablet by mouth every night at bedtime for mood stabilization." This medication was not administered to Individual #1 as prescribed at 8:00PM from 9/1/2024 through 9/4/2024 with the reason listed as, "Medication not present." | Medication errors include the following: Failure to administer a medication. | The Certified Investigator submitted the medication errors. (9492181, 9493230, 9493256, 9492184, 9493282, 9493297, 9493304) (9/27-30/2024)
The Operations Manager added the Medication Deliveries/ Out of Medications/ Disposing Medications protocol to ensure medications are present at the home for administration. (9/24/2024)
The Program Manager, Program Specialist, and Residential Supervisors were trained on this new protocol. (9/30-10/3/2024)
Medication Deliveries: Medications are delivered to the main office per a schedule set by PDC pharmacy. The following protocol must be followed to ensure compliance with the regulations 6400.166:
1. Every 3rd Thursday of the month, Supervisors are to ensure that medication lock boxes are present at the office (after 12pm med pass).
2. All medications must be counted to ensure the cycle count is accurate. Supervisors are to utilize a printed MAR and the Packaging slip to complete this count.
3. When reviewing the delivered medications, the following items must be reviewed to ensure the Medication Label and MAR match exactly:
a. Individual Name b. Name of the Prescriber c. Name of Medication
d. Strength of Medication e. Dosage form f. Dose of medication
g. Route of Administration h. Frequency of administration i. Diagnosis or purpose for the medication, including pro re nata J. Brand Name k. time of administration
4. Any incorrect information found on the MAR must be submitted to the Program Specialist for corrections. These corrections must be completed on the same day.
5. This process must be completed every 3rd Thursday at the Program Meeting.
6. Supervisors will sign off on the Medications form monthly verifying that they have completed the steps above.
7. Medications will be delivered back to the homes before the next med pass at 4pm.
8. Ozempic and any subcutaneous medications will be kept at the office for safekeeping and proper administration.
9. Medication Errors are required to be submitted in EIM within 72 hours and reported to the Individuals designee.
The Program Manager, Program Specialist, and Residential Supervisors were trained on this new protocol. (9/30-10/3/2024) |
09/27/2024
| Implemented |