| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | At 10:14AM on 9/18/2024, two bottles of Pine Sol, an aerosol spray can of All-Purpose Cleaner, a bottle of Fabuloso, two bottles of Cloralen and an aerosol can of Glass Cleaner were unlocked and accessible under the sink in the kitchen of the home. At 10:25AM on 9/18/2024, two aerosol spray cans of Scrubbing Bubbles Bathroom Grime Fighter, an aerosol spray bottle of Sprayway All Purpose Cleaner and a bottle of Lysol Advanced Power Clinging Gel were unlocked and accessible in a cabinet under the sink in the bathroom on the second floor of the home.
Individual #1's assessment, completed 8/10/2024, states that Individual needs arm's length supervision while using cleaning products to ensure that the products are not mixed together. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The Program Specialist reassessed individual and sent an email (9/26/2024) to the SC requesting the following verbiage be removed from the current ISP ¿Staff monitors him and provides arm¿s length supervision while he uses these products to ensure he uses them safely and does not mix chemicals¿. The individual is poison safe as stated in the current ISP. The individual has a job cleaning and routinely uses cleaning chemicals safely. The ISP will now reflect the Individual is poison safe and does not require monitoring. |
09/27/2024
| Implemented |
| 6400.82(f) | At 10:25AM on 9/18/2024, there was no trash receptacle in the bathroom on the second floor of the home. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | The Individual was educated about the importance of having a trash can in the bathroom. The Individual was provided with an additional small trash can for his room, so he can leave the bathroom trash can in place. Staff are visually checking to ensure the bathroom garbage can is present when on shift. A house meeting was held to discuss the importance of this regulation and reviewed all required items in a bathroom. 9/30/2024 |
09/30/2024
| Implemented |
| 6400.101 | At 10:20AM on 9/18/2024, there was a slide lock on the door in the laundry room leading to the back exit in the basement of the home. At 10:23AM on 9/18/2024, there was a sliding chain lock on the door in the basement leading to the back patio of the home. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Contracted Handyman to remove the slide locks on 9/19/2024. Reviewed the regulation and discussed different types of obstructions and what they may look like so staff are aware of the many forms. |
09/19/2024
| Implemented |
| 6400.110(e) | At 10:58AM on 9/18/2024, the smoke detector on the first floor was not interconnected with the smoke detectors in the basement and second floor of the home. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | Contracted Handyman performed Smoke detector maintenance, ensuring all smoke detectors were connected and could be set off from all locations. Site staff and management have been retrained in how to properly set off smoke detectors. Staff are to press quickly and not hold button. 9/19/2024. |
09/19/2024
| Implemented |
| 6400.163(h) | Individual #1 was prescribed Ibuprofen 600MG with instructions to, "Take 1 tablet by mouth every eight hours as needed for mild pain for 7 days." This discontinued medication remained in Individual #1's medication storage container at 10:48AM on 9/18/2024. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The Operations Manager added a new Medication Deliveries/Disposal Protocol that gives clear instructions to the Program Specialist concerning the protocol for disposal of medications: Program Specialist received this training on 9/30/2024.
Disposing of Medications
1. When medications are discontinued by the Licensed professional, the Program Specialist will ensure the medication is removed from the home on the same day.
2. All medication bubble packs must be removed from the houses once they have been administered.
3. The Program Specialist and Program Manager will utilize the RX Destroyer to dispose of any discontinued medications.
4. The disposal form will be completed and signed.
5. All medication bubble packs will be destroyed to ensure privacy of the Individuals. |
09/30/2024
| Implemented |
| 6400.166(a)(7) | Individual #1 is prescribed Mucus Relief Tab 600 MG ER. Individual #1's September 2024 Medication Administration Record reads, "Strength: 500MG." | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | The Operations Manager added a new Medication Deliveries/Disposal Protocol that gives clear directions to the Program Specialist on how to check the MAR/ Label. (9/24/2024) This process will be completed monthly.
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. |
09/24/2024
| Implemented |
| 6400.166(b) | Individual #1 was prescribed Ibuprofen 600MG with instructions to, "Take 1 tablet by mouth every eight hours as needed for mild pain for 7 days." This prescription was filled on 5/21/2024 and dispensed pills on the bubble pack were dated beginning 5/25/2024. This discontinued medication was inside Individual #1's medication box at 10:48AM on 9/18/2024. A dispensed pill was dated 8/8/2024. This medication was not on Individual #1's August or September Medication Administration Record and the medication administration was not documented as administered. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The Operations Manager added a Signup agreement that documented the proper medication administration and documentation process. DSPs received this training from their House Supervisors, and it is reviewed every time they log into Therap to administer medications.
Title: Electronic MAR Documenting
Details: When Administering medications please follow these steps:
Part 1 Preparation
1. Identify Individual and Medication Box
2. Prepare a clean space to pop the medications
3. Gather medication cups, water, etc.
4. Open the medication box
5. Wash Hands
Part 2 Administration
1. Check 1: Check the MAR and the Medication Label
2. Check 2: Check the MAR and the Medication Label
3. Check 3: Check the MAR and the Medication Label
4. Administer the Medication
5. Observe after administration to ensure medication has been swallowed
Part 3 Completion
1. Recheck the Rights (IMDTR)
2. Document on the MAR and Bubble pack
3. Put away the medication
4. Wash Hands
5. Observe for Effects
Please contact William H (PM with any questions) 412.699.912 |
09/24/2024
| Implemented |