| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 20.34 | The following records were requested by the Department from the agency on 5/18/23, but were not received: a) Individual #1's 5/7/23 Hospital ER Visit & discharge papers; b) Medical treatment follow-up appointments Individual #1 has had since their ER visit on 5/7/23; c) Agency certified investigations completed thus far for neglect EIM Inc. #9211616 and abuse EIM Inc.# 9211571; d) Individual #1's March and April 2023 Medication Administration Records; e) Most recent physical examinations and tuberculosis tests for Direct Support Professional #1 and Direct Support Professional #2; f) All behavior/ incidents reported in Therap since Individual #1's admission on 2/27/23; and g) Staff schedules for the home since Individual #1's admission on 2/27/23. | The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients. | Staff that was responsible for paperwork submission was removed from admin duties. |
07/28/2023
| Implemented |
| 6400.16 | Direct Support Professional #1 and Direct Support Professional #2 did not provide adequate supervision of a 2:1 staffing ratio as specified in individual #1's 5/2/23 individual plan and as directed by their supports coordinator. Direct Support Professional #1 took Individual #1 out in the agency vehicle alone for approximately three hours from 12:00 PM to 3:00 PM on May 7, 2023. On May 7, 2023, Direct Support Professional #1 physically assaulted Individual #1 several times with a metal spatula in an agency vehicle, leaving cuts all over their face, across their nose, in their scalp, and on their lip. The assault also left Individual #1 with bruising under both eyes and on their upper left arm. On May 7, 2023, Direct Support Professional #1 attempted to cover Individual #1's fresh, open wounds with toothpaste while Direct Support Professional #2 took no intervention. On May 7, 2023, Direct Support Professional #1, Direct Support Professional #2, and Program Specialist #3 did not take immediate action to protect the health, safety, and well-being of Individual #1, as they were left in need of medical attention from approximately 3:00 PM to 5:00 PM before 9-1-1 was called. The agency failed to secure Individual #1's home by allowing Direct Support Professional #1 to break in on May 8, 2023, from the basement through the sliding glass door with a broken lock. While in Individual #1's presence on May 8, 2023, Direct Support Professional #1 argued with Direct Support Professional #4 about what had happened during the outing on May 7, 2023, and yelled, "Don't f--king touch me!" to Individual #1 when they attempted to hug Direct Support Professional #1. Nine of individual #1's prescribed medications were not administered at various times from May 1, 2023 to May 10, 2023. All of the direct support professionals interviewed lacked an understanding of how to manage Individual #1's aggression and have been applying arm holds, floor pins, and other physical restrains that have not been written in a restrictive plan and approved by a Human Rights Committee. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | EIMs were filed for all reportable incidents and are currently being investigated. The lock on the sliding glass door has been replaced. BSC was contacted to update individuals BSP and to also retrain the staff on the updated plan. |
07/28/2023
| Implemented |
| 6400.18(b) | On 5/12/23, the following prescribed medications for Individual #1 were found not to have been administered at 8:00 AM on 5/6/23 and 5/7/23: Cetrizine HCL 10 MG Tab.; Clonazepam 1 MG Tab.; Famotidine 20 MG Tab.; Lithium Carbonate ER 300 MG Tab.; Metformin HCL ER 500 MG Tab.; NAC 600 MG Cap.; Propranolol 60 MG Tab.; Quetiapine Fumarate 300 MG Tab.; and Vitamin B-12 250 MCG Tab. The following prescribed medications for Individual #1 were found not to have been administered at 2:00 PM on 5/6/23, 5/7/23, and 5/9/23: Clonazepam 1 MG Tab.; NAC 600 MG Cap.; Propranolol 60 MG Tab.; and Quetiapine Fumarate 300 MG Tab. The following prescribed medications for Individual #1 were found not to have been administered at 8:00 PM on 5/1/23, 5/3/23, 5/4/23, 5/5/23, 5/6/23, and 5/7/23: Clonazepam 1 MG Tab.; NAC 600 MG Cap.; and Propranolol 60 MG Tab. The following prescribed medications for Individual #1 were found not to have been administered at 8:00 PM on 5/1/23, 5/3/23, 5/4/23, 5/5/23, 5/6/23, 5/7/23, 5/8/23, and 5/10/23: Lithium Carbonate ER 300 MG Tab.; Olanzapine 5 MG Tab.; and Quetiapine Fumarate 300 MG Tab. The agency has yet to report these medication errors in the Department's Enterprise Incident Management system. | Written policies and procedures on the prevention, reporting, investigation and management of unusual incidents shall be developed and kept at the home.
| Incidents have been reported in EIM. Management reviewed the pill packs and discussed with staff that in fact the meds were given, they were not documented that they were given. |
07/28/2023
| Implemented |
| 6400.43(b)(1) | CEO #5 did not ensure that staff were properly trained on the following policies to ensure implementation: a) Freedom Now Home Care's Emergency Medical Plan states, "If a medical emergency arises for any of the individuals, they will be transported by the company vehicle, or if deemed necessary after calling 9-1-1, by ambulance to nearest hospital for treatment and further evaluation." On May 7, 2023, Individual #1 was neither transported to the nearest hospital by staff nor were emergency medical services immediately called; b) Freedom Now Home Care's Incident Management Policy states, "FNHC office administration will create an in-depth incident report for review by management after a through certified investigation has been done by the office administration." In the weeks leading up to May 7, 2023, on May 7, 20223, and on May 8, 2023, there were three confirmed incidents of abuse that the office administration had failed to report in the Department's Enterprise Management System and for which to conduct certified investigations. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | Incidents were filed in EIM and are currently being investigated. Staff will be retrained on the importance of contacting law enforcement, emergency medical services, management on call immediately upon discovery to ensure that the health and safety of the individual is kept at the forefront. |
07/28/2023
| Implemented |
| 6400.43(b)(3) | CEO #5 did not ensure the health and safety of Individual #1 in the following manner: a) Staff are not properly trained on the agency's emergency medical policy, incident management policy, and restrictive procedure policy; b) The agency does not have a current, accurate, and comprehensive assessment that was completed either within either 12 months prior to Individual #1's admission on 2/27/23 or 60 days afterwards; c) The agency has not properly trained direct support staff in how to implement Individual #1's behavior support plan to manage their aggression and challenging conduct, resulting in their subjection to direct support staffs' use of unapproved arm holds, floor pins, and other physical restraints; d) Nine of Individual #1's prescribed medications were not administered at various times from May 1, 2023 to May 10, 2023, and the agency has not reported these errors in the Department's Enterprise Incident Management system, determined their causes, or implemented any corrective measures for prevention; e) Direct Support Professional #1 had committed two separate acts of physical abuse towards Individual #1 in the weeks leading up to May 7, 2023, that the agency did not address by reporting in the Department's Enterprise Management System, by separating Direct Support Professional #1 from Individual #1 to protect their health and safety, and by conducting certified investigations into those abuse incidents. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. | Staff will be retrained on the emergency medical policy, incident management policy, and restrictive procedure policy. Individual assessment was completed. BSC was contacted to get a BSP training completed once the plan is updated. Incidents were reported in EIM and are currently being investigated. |
07/28/2023
| Implemented |
| 6400.63(a) | On 5/12/23, the hot water temperature at the kitchen sink measured 122.7 degrees F. at 10:13 AM. The hot water temperature at the bathroom sink in the basement measured 122.3 degrees F. at 10:19 AM. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | Management adjusted hot water tank to be under the 120 degree regulation |
07/28/2023
| Implemented |
| 6400.64(a) | On 5/12/23, a white garage bag full of trash was observed leaning against one of the two outdoor trash cans located underneath the side decking and steps off the kitchen door at 10:44 AM. | Clean and sanitary conditions shall be maintained in the home. | Garbage can was purchased to prevent the overflow of garbage bags outside. |
07/28/2023
| Implemented |
| 6400.64(f) | On 5/12/23, napkins, sanitizer wipes, and other random trash were found strewn on the ground next to the outdoor trash cans located underneath the side decking and steps off the kitchen door at 10:44 AM. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | Garbage can was purchased to prevent the overflow of garbage bags outside. |
07/28/2023
| Implemented |
| 6400.66 | On 5/12/23 at 10:14 AM, there was no light bulb found in the ceiling light receptable located at the bottom of the stairs causing insufficient lighting in this area, which is also comprised of laundry facilities. No other lighting sources were located nearby. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Management placed a light bulb in the receptacle in order to ensure proper lighting. |
07/28/2023
| Implemented |
| 6400.67(b) | On 5/12/23 at 10:18 AM, water was found leaking around the base of the toilet on the bathroom floor located in the basement. At 10:22 AM, a puddle of standing water was observed surrounding the main floor drain in the basement. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Management contacted maintenance man to repair the water leaks and clogs. |
07/28/2023
| Implemented |
| 6400.72(a) | On 5/12/23 at 10:27 AM, the living room's only two windows were observed without screens. At 10:35 AM, in the empty storage room across from the bathroom on the upper level, the window located to the left of the room's entryway was found without a screen. At 10:38 AM, the vacant bedroom's only two windows were found without screens. At 10:39 AM, the only two windows in Individual #1's bedroom were observed without screens. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Management contacted window repair company to replace / repair screens in the windows |
07/28/2023
| Implemented |
| 6400.72(b) | On 5/12/23 at 10:31 AM, the only window located in the upper-level hallway was found with several holes and tears. At 10:35 AM, in the empty storage room across from the bathroom on the upper level, the window situated directly across from the room's entryway was observed with a screen that had several holes and tears. | Screens, windows and doors shall be in good repair. | Management contacted window repair company to replace / repair screens in the windows |
07/28/2023
| Implemented |
| 6400.72(c) | On 5/12/23, the sliding glass door leading to the outside from the basement was discovered without an operable lock at 10:16 AM. | Outside doors shall have operable locks. | Management contacted maintenance man and he replaced the door lock. |
07/28/2023
| Implemented |
| 6400.73(a) | On 5/12/23 at 10:15 AM, the first handrail on the basement stairwell was found loose and unsecured to the wall. This stairwell exceeds two steps. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | Management contacted maintenance man to repair the handrail. |
07/28/2023
| Implemented |
| 6400.76(a) | On 5/12/23 at 10:27 AM, one of the two futons, the one facing the windows in the living room, was observed with a broken structural seating base, compromising its safety and integrity. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Management ordered new couch for the home. |
07/28/2023
| Implemented |
| 6400.81(k)(6) | During the on-site health and safety inspection on 5/12/23, a mirror was not found in Individual #1's bedroom. Individual #1 does not have a restriction on this item in their individual plan. | In bedrooms, each individual shall have the following: A mirror. | Management ordered a mirror for individual's room |
07/28/2023
| Implemented |
| 6400.82(f) | On 5/12/23, the bathroom located in the basement was observed at 10:24 AM without a trash receptacle. | 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. | Management ordered a trash receptacle for the bathroom. |
07/28/2023
| Implemented |
| 6400.101 | On 5/12/23, the basement's only outside exit, which is a sliding glass door, was discovered at 10:16 AM with a wooden dowel rod placed on its track, preventing the door from opening. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Management removed the wooden dowel rod for the door. |
07/28/2023
| Implemented |
| 6400.171 | On 5/12/23, the following observations were made at 10:11 AM: 31 eggs were found uncovered, laying on 2 cardboard flats in the refrigerator with no dates indicating when they had been opened or when they expire for prevention of contamination; a ripped open bag of browning romaine lettuce with a use-by-date of 4/24/23; and one gallon of Member's Mark Vitamin D Milk with a best-if-used-by-date of 4/28/23. | Food shall be protected from contamination while being stored, prepared, transported and served.
| Management removed the food from the refrigerator |
07/28/2023
| Implemented |
| 6400.181(a) | Individual #1, date of admission 2/27/23, does not have an assessment. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Management reviewed current assessment from prior provider and updated current assessment from FNHC, |
07/28/2023
| Implemented |
| 6400.214(b) | On 5/12/23, the following current records for Individual #1 were not found at the home: a demographics page or face Sheet, incident reports or behavior logs, or a comprehensive assessment. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| Management purchased binders to have paper copies of all records instead of utilizing it via online access. |
07/28/2023
| Implemented |
| 6400.18(a)(4) | Direct Support Professional #1 had committed two separate acts of physical abuse towards Individual #1 in the weeks leading up to May 7, 2023, that the agency did not report in the Department's Enterprise Management System. One incident involved Direct Support Staff #1 pushing Individual #1 down onto the steps leading up to their bedroom at the agency home, and the other occurred when Direct Support Professional #1 punched Individual #1 in the nose while at the agency home. On May 8, 2023, Individual #1 was exposed to psychological abuse that the agency also did not report in the Department's Enterprise Management System, when Direct Support Professional #1 had broken in the agency home, argued in front of Individual #1 with Direct Support Professional #4 about what happened during the outing on May 7, 2023, and yelled, "Don't f--king touch me!" to Individual #1 when they attempted to hug Direct Support Professional #1. | 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 24 hours of discovery by a staff person:
Abuse, including abuse to a individual by another client.
| Management filed incidents in EIM. Management will retrain staff on reporting incidents to management in a timely manner. |
07/28/2023
| Implemented |
| 6400.18(f) | On May 7, 2023, Direct Support Professional #1, Direct Support Professional #2, and Program Specialist #3 did not take immediate action to protect the health, safety, and wellbeing of Individual #1, as they were left in need of medical attention from approximately 3:00 PM to 5:00 PM before 9-1-1 was called by Direct Support Professional #1 at the direction of Program Specialist #3. In the weeks leading up to May 7, 2023, there were two separate acts of physical abuse committed by Direct Support Professional #1 towards Individual #1, involving them being pushed and punched by Direct Support Professional #1. In both instances, the agency did not take immediate action to protect the health, safety, and well-being of Individual #1 upon initial knowledge of these incidents of abuse by separating Direct Support Professional #1 from Individual #1 and by notifying law enforcement and/or protective services. | The home shall take immediate action to protect the health, safety and well-being of the individual following the initial knowledge or notice of an incident, alleged incident or suspected incident. | Incidents were filed in EIM and the proper authorities were notified. Staff will be retrained on reporting timelines and to notify the proper authorities immediately upon discovery. |
07/28/2023
| Implemented |
| 6400.18(h)(3) | Direct Support Professional #1 had committed two separate acts of physical abuse towards Individual #1 in the weeks leading up to May 7, 2023, involving Individual #1 being pushed about two weeks prior and then punched at an unknown date by Direct Support Professional #1. On May 8, 2023, Direct Support Professional #1 broke into the agency home, argued with Direct Support Professional #4 in the presence of Individual #1 about what had happened during the outing on May 7, 2023, and yelled, "Don't f--king touch me!" to Individual #1 when they attempted to hug Direct Support Professional #1. The agency did not initiate investigations for any of these incidents within 24 hours of discovery by staff. | A Department-certified incident investigator shall conduct the investigation of the following incidents: Abuse, including abuse to an individual by another individual. | Incidents were filed in EIM and the proper authorities were notified. Staff will be retrained on reporting timelines and to notify the proper authorities immediately upon discovery. |
07/28/2023
| Implemented |
| 6400.32(r) | During the on-site health and safety inspection on 5/12/23, Individual #1's bedroom door was observed with a privacy door lock, which can be opened from the outside by a thumbnail or any common straightedged object. Individual #1's record did not contain a bedroom door lock declination. At 11:19 AM, Individual #1 stated that they wanted to have a bedroom door lock. | An individual has the right to lock the individual's bedroom door. | Management will review with team about individual having a bedroom door lock to ensure individuals health and safety due to the individuals behaviors. |
07/28/2023
| Implemented |
| 6400.45(c) | Direct Support Professional #1 and Direct Support Professional #2 did not provide adequate supervision of a 2:1 staffing ratio as specified in individual #1's 5/2/23 individual plan and as directed by their supports coordinator. Direct Support Professional #1 took Individual #1 out in the agency vehicle alone for approximately three hours from 12:00 PM to 3:00 PM on May 7, 2023. | An individual may be left unsupervised for specified periods of time if the absence of direct supervision is consistent with the individual's assessment and is part of the individual plan, as an outcome which requires the achievement of a higher level of independence. | Management filed incidents in EIM. Staff will be retrained on individuals staffing ratios |
07/28/2023
| Implemented |
| 6400.163(a) | On 5/12/23 at 11:25 AM, a Clonazepam 1 MG tablet was discovered popped out of its original labeled blister packaging, laying at the bottom of the toolbox that stored Individual #1's medications. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | Management disposed of the loose pill. |
07/28/2023
| Implemented |
| 6400.163(d) | On 5/12/23 at 11:24 AM, Induvial #1's medications were found stored in a toolbox with a key lock fastened to it. However, the key to the fastened lock was kept unsecured and visible in a clear plastic lid compartment of the toolbox. At 11:25 AM, Individual #1's prescribed controlled substance, Clonazepam Tab 1 MG, was found in a toolbox secured by a key lock. However, the key to the fastened lock was kept unsecured and visible in a clear plastic lid compartment of the toolbox. The toolbox storing their medications was not observed to be locked up or secured within an area itself. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | Management placed the medication box in the staff office in the filing cabinet. |
07/28/2023
| Implemented |
| 6400.165(g) | A new medication, Olanzapine 10 mg---Take 1 tablet nightly by mouth---was prescribed at Individual #1's 3-month psychiatric medication review on 5/16/23. However, the review did not include the reason this medication was prescribed. | 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. | Management created a psychiatric medication review form that includes the reason for medication being prescribed. Management will contact doctors office to change wording on prescription to include diagnosis / reason for prescribing. |
07/28/2023
| Implemented |
| 6400.166(a)(4) | On 5/12/23 at 11:30 AM, a bottle of Ibuprofen 100 Capsules/ 200 MG---Take 1 caplet every 4-6 hours as symptoms persist---was discovered onsite prescribed as a pro re nata medication but was not recorded on Individual #1's May 2023 Medication Administration Record and, therefore, was missing the following element: Name of the medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | Management removed the medication from the home as it was not prescribed. Requested PRN prescription from PCP. |
07/28/2023
| Implemented |
| 6400.166(a)(5) | On 5/12/23 at 11:30 AM, a bottle of Ibuprofen 100 Capsules/ 200 MG---Take 1 caplet every 4-6 hours as symptoms persist---was discovered onsite prescribed as a pro re nata medication but was not recorded on Individual #1's May 2023 Medication Administration Record and, therefore, was missing the following element: The medication's strength. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | Management removed the medication from the home as it was not prescribed. Requested PRN prescription from PCP. |
07/28/2023
| Implemented |
| 6400.166(a)(6) | On 5/12/23 at 11:30 AM, a bottle of Ibuprofen 100 Capsules/ 200 MG---Take 1 caplet every 4-6 hours as symptoms persist---was discovered onsite prescribed as a pro re nata medication but was not recorded on Individual #1's May 2023 Medication Administration Record and, therefore, was missing the following element: The medication's dosage form. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | Management removed the medication from the home as it was not prescribed. Requested PRN prescription from PCP. |
07/28/2023
| Implemented |
| 6400.166(a)(7) | On 5/12/23 at 11:30 AM, a bottle of Ibuprofen 100 Capsules/ 200 MG---Take 1 caplet every 4-6 hours as symptoms persist---was discovered onsite prescribed as a pro re nata medication but was not recorded on Individual #1's May 2023 Medication Administration Record and, therefore, was missing the following element: Dose of the medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | Management removed the medication from the home as it was not prescribed. Requested PRN prescription from PCP. |
07/28/2023
| Implemented |
| 6400.166(a)(8) | On 5/12/23 at 11:30 AM, a bottle of Ibuprofen 100 Capsules/ 200 MG---Take 1 caplet every 4-6 hours as symptoms persist---was discovered onsite prescribed as a pro re nata medication but was not recorded on Individual #1's May 2023 Medication Administration Record and, therefore, was missing the following element: The medication's route of administration. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | Management removed the medication from the home as it was not prescribed. Requested PRN prescription from PCP. |
07/28/2023
| Implemented |
| 6400.166(a)(9) | On 5/12/23 at 11:30 AM, a bottle of Ibuprofen 100 Capsules/ 200 MG---Take 1 caplet every 4-6 hours as symptoms persist---was discovered onsite prescribed as a pro re nata medication but was not recorded on Individual #1's May 2023 Medication Administration Record and, therefore, was missing the following element: The medication's frequency of administration. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | Management removed the medication from the home as it was not prescribed. Requested PRN prescription from PCP. |
07/28/2023
| Implemented |
| 6400.166(a)(11) | On 5/12/23 at 11:30 AM, a bottle of Ibuprofen 100 Capsules/ 200 MG---Take 1 caplet every 4-6 hours as symptoms persist---was discovered onsite prescribed as a pro re nata medication but was not recorded on Individual #1's May 2023 Medication Administration Record and, therefore, was missing the following element: The medication's diagnosis or purpose, including pro re nata. | 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. | Management removed the medication from the home as it was not prescribed. Requested PRN prescription from PCP. |
07/28/2023
| Implemented |
| 6400.167(a)(1) | On 5/12/23, the following prescribed medications for Individual #1 were found not to have been administered at 8:00 AM on 5/6/23 and 5/7/23: Cetrizine HCL 10 MG Tab.; Clonazepam 1 MG Tab.; Famotidine 20 MG Tab.; Lithium Carbonate ER 300 MG Tab.; Metformin HCL ER 500 MG Tab.; NAC 600 MG Cap.; Propranolol 60 MG Tab.; Quetiapine Fumarate 300 MG Tab.; and Vitamin B-12 250 MCG Tab. The following prescribed medications for Individual #1 were found not to have been administered at 2:00 PM on 5/6/23, 5/7/23, and 5/9/23: Clonazepam 1 MG Tab.; NAC 600 MG Cap.; Propranolol 60 MG Tab.; and Quetiapine Fumarate 300 MG Tab. The following prescribed medications for Individual #1 were found not to have been administered at 8:00 PM on 5/1/23, 5/3/23, 5/4/23, 5/5/23, 5/6/23, and 5/7/23: Clonazepam 1 MG Tab.; NAC 600 MG Cap.; and Propranolol 60 MG Tab. The following prescribed medications for Individual #1 were found not to have been administered at 8:00 PM on 5/1/23, 5/3/23, 5/4/23, 5/5/23, 5/6/23, 5/7/23, 5/8/23, and 5/10/23: Lithium Carbonate ER 300 MG Tab.; Olanzapine 5 MG Tab.; and Quetiapine Fumarate 300 MG Tab. The above findings were determined using Individual #1's May 2023 Medication administration Record and observations made from the original blister packaging of the medications. | Medication errors include the following: Failure to administer a medication. | Management filed incident reports in EIM. Staff will be retrained on proper medication practices. |
07/28/2023
| Implemented |
| 6400.167(b) | On 5/12/23, the following prescribed medications for Individual #1 were found not to have been administered at 8:00 AM on 5/6/23 and 5/7/23: Cetrizine HCL 10 MG Tab.; Clonazepam 1 MG Tab.; Famotidine 20 MG Tab.; Lithium Carbonate ER 300 MG Tab.; Metformin HCL ER 500 MG Tab.; NAC 600 MG Cap.; Propranolol 60 MG Tab.; Quetiapine Fumarate 300 MG Tab.; and Vitamin B-12 250 MCG Tab. The following prescribed medications for Individual #1 were found not to have been administered at 2:00 PM on 5/6/23, 5/7/23, and 5/9/23: Clonazepam 1 MG Tab.; NAC 600 MG Cap.; Propranolol 60 MG Tab.; and Quetiapine Fumarate 300 MG Tab. The following prescribed medications for Individual #1 were found not to have been administered at 8:00 PM on 5/1/23, 5/3/23, 5/4/23, 5/5/23, 5/6/23, and 5/7/23: Clonazepam 1 MG Tab.; NAC 600 MG Cap.; and Propranolol 60 MG Tab. The following prescribed medications for Individual #1 were found not to have been administered at 8:00 PM on 5/1/23, 5/3/23, 5/4/23, 5/5/23, 5/6/23, 5/7/23, 5/8/23, and 5/10/23: Lithium Carbonate ER 300 MG Tab.; Olanzapine 5 MG Tab.; and Quetiapine Fumarate 300 MG Tab. The agency did not provide documentation of these medication errors, any corresponding follow-up actions taken, and the prescriber's response. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | Management filed incident reports in EIM. Staff will be retrained on proper medication practices. |
07/28/2023
| Implemented |
| 6400.194(a) | Several direct support staff having been applying arm holds, floor pins, and other physical restraints on Individual #1 that have not been written in a restrictive plan and approved by a Human Rights Committee. | If a restrictive procedure is used, the home shall use a human rights team. The home may use a county mental health and intellectual disability program human rights team that meets the requirements of this section. | Management filed an incident report in regards to this and is currently being investigated. BSC is currently updating the BSP and once updated, will retrain staff. |
07/28/2023
| Implemented |