| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.32(r)(1) | At 10:55AM, there was a thumb turn lock on individual #1's bedroom door with no unique designated mechanism to lock and unlock the door. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | The thumb-turn lock was replaced with a mechanism accessible to Individual #1 on 11/29/2024. |
11/29/2024
| Implemented |
| 6400.166(a)(9) | Individual #1 is prescribed Ondansetron 4MG tablets. The November 2024 Medication Administration Record states, "Place 1 tablet under tongue and dissolve 3 times daily as needed for nausea or vomiting." The medication label states, "Dissolve one tablet under the tongue every 6 hours as needed for nausea or vomiting." Individual #1 is prescribed Mucus Relief ER 600MG tablets. The November 2024 Medication Administration Record states, "Take 1 tablet by mouth twice daily as needed for cough and congestion." The medication label states, "Take by mouth 1 tablet once daily as needed for cough and congestion." Individual #1 is prescribed MAPAP (Acetaminophen) 325MG. The November 2024 Medication Administration Record states, "Take by mouth 1 tablet four times daily as needed pain or fever." The medication label states, "Take 1 tablet by mouth every 4 hours as needed for mild pain (PAIN SCALE 1-3). | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | On 11/26/2024 the program specialist took all medication labels and MARs for Individual #1 back to the pharmacy to be reviewed and corrected to match prescriber instructions.
11/26/2024 All medication labels and MARs for Individual #1 were reviewed and corrected. |
11/29/2024
| Implemented |
| 6400.166(a)(11) | Individual #1 is prescribed MAPAP (Acetaminophen) 325MG. The November 2024 Medication Administration Record states, "Take by mouth 1 tablet four times daily as needed pain or fever." The medication label states, "Take 1 tablet by mouth every 4 hours as needed for mild pain (PAIN SCALE 1-3). | 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. | On 11/26/2024 the program specialist reached out to the pharmacy to update the purpose for MAPAP (Acetaminophen) 325MG and it was updated in the MAR to include "mild pain (pain scale 1-3)"
On 11/26/2024 the program specialist reviewed All current MARs to ensure each medication's purpose is clearly documented. |
11/29/2024
| Implemented |
| 6400.166(b) | As of 10:22AM, all of Individual #1's prescribed medications were already initialed as administered for the 8PM doses on 11/26/2024. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | On 11/26/2024 Staff responsible for the violation was removed from the scheduled until she completes another Medication training on MAR protocols. |
12/06/2024
| Implemented |
| 6400.166(d) | Individual #1 is prescribed Zepbound 2.5MG/0.5ML with instructions to, "Inject 0.5ML subcutaneously every 7 days." Individual #1 is reportedly taken to the hospital for these injections to be administered by the medical staff. Individual #1's injections were completed on 11/6/2024, 11/13/2024 and not again until 11/22/2024. The medication was not administered in accordance with the directions of the prescriber, | The directions of the prescriber shall be followed. | Individual #1's refused to go to the appointment on 11/20/2024 for her Zepbound injections A refused form was filled out and it was presented to the licensing representative.
The team lead will oversee scheduling and transportation for medical appointments related to injections. |
11/29/2024
| Implemented |