| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(a) | The last physical in the record for individual #1 is dated 8/30/23. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #1 had a physical on 8/7/24. (Attachment # 16, 16a, 16b) The paperwork was at the office to be scanned for another monitoring. While it was not in the home, it was completed. The Program Specialists were retrained on the importance of returning paperwork to the home binder in a timely manner so the binders remain in compliance. (Attachment # 8) |
11/08/2024
| Implemented |
| 6400.144 | (Repeat from 4/24/24) Individual #1 had an appointment with the PCP on 8/7/24. At that appointment an MRI of the abdomen with and without contrast was recommended. At the time of the inspection on 10/8/24, this test was not scheduled or completed.
At the time of the inspection on 10/8/24, the following PRN medication was on the MAR but not available in the home: Acetaminophen 500mg (order is to take 1000mg every 6hrs as 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.
| MRI was scheduled for 10/17/24. (Attachment # 17) Individual #1 refused the appointment. All efforts were made using the BSP strategies of telling the individual well ahead of time, giving time and space, encouragement and education not getting panicked or upset, and trying again. Individual #1 still refused.
The appointment was rescheduled for 12/13/24. (Attachment #18)
PRN Medication Acetaminophen 500mg was purchased and taken to the home. (Attachment # 19) |
11/08/2024
| Not Implemented |
| 6400.214(b) | At the time of the inspection on 10/8/24, the most recent assessment was not available in the home. The assessment in the home was dated 8/18/23. Also, the most recent ISP was not available in the home. The ISP in the home was dated 10/26/23. The ISP was last updated 10/8/24 per HCSIS. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| The most recent ISP and assessment for individual # 1 were taken to the home and added to the binder. (Attachment # 22 and #23) |
11/08/2024
| Not Implemented |
| 6400.217 | At the time of the inspection on 10/8/24 there was no current release of information available in the record. The last release of information form was valid only from 2/1/23 through 2/1/24. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| Release of Information form was sent to the individual's guardian on 11/7/24. |
11/08/2024
| Implemented |
| 6400.34(a) | Individual #1 was informed of individual rights on 3/3/23 and not again until 10/8/24, outside of the annual timeframe. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | All individual's annual packets were reviewed to ensure compliance with the Individual Rights statements. |
11/08/2024
| Not Implemented |
| 6400.165(g) | Individual #1 is prescribed Sertraline for a diagnosis of depression/anxiety. At the time of the inspection, the only documented medication review was dated 4/12/23. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | A medication review is performed every time the individual sees their PCP. The PCP prescribes the medication and reviews it. An appointment was set up to specifically review Individual #1's psychotropic medication.
Individual #1's PCP appointment form has been updated to include a section specifically for psychotropic medication review. Program Specialists were retrained on quarterly reviews for psychotropic medications. |
11/08/2024
| Not Implemented |
| 6400.166(b) | (Repeat from 4/24/24) At the time of the inspection on 10/8/24, the October 2024 MAR did not include the initials of the staff that administered the 8am dose of Cinacalcent 30mg @ 8am on 10/8/24. Also, the medication Sevelamer Carbonate 800mg is ordered to be given 3 times per day. The medication is to be put on "hold" if individual #1 does not eat and the MAR is to be marked with an "H" instead of staff initials. At the time of the inspection on 10/8/24, the 10am dose pf this medication was not initialed or marked with an "H". Staff on shift explained that individual #1 did not eat by 10am so the medication could not be given. The MAR should have been marked with an "H" for the 10/8/24 10am dose. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The "Hold" procedure was explained to the Lead DSP and the House Supervisor. The staff were retrained on MAR documentation on 10/17/24. (Attachment #29) The staff who gave the Cinacalcet 30 mg on 10/8/24 was contacted to complete their documentation. (Attachment # 30) |
11/08/2024
| Implemented |
| 6400.167(a)(1) | (Repeat from 4/24/24) Individual #1 is prescribed Clotrimazole 1% cream to apply to affected areas twice daily. On the September 2024 MAR it was documented as administered only once on 9/5/24, 9/10/24, and 9/11/24. It was not documented as administered at all on 9/6/24, 9/7/24, 9/8/24, or 9/9/24. | Medication errors include the following: Failure to administer a medication. | The cream ran out and there were no more refills. The PCP was contacted for a refill. On 10/17/24, staff and the person responsible for medications were retrained by the trainer on getting refills when there is 7 days' worth of medication left. (Attachment #31) |
11/08/2024
| Implemented |