| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(7) | Most recent GYN exam for individual #1 dated 1/27/21 states follow up is 1 year, and next pap is 5 years 'if normal'
Additionally a GYN exam was recommended by PCP on a 12/29/21 appointment. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Due to COVID restrictions in 2021, 2022 GYN appointments could not be scheduled in advance and were waitlisted for approximately 4-6 months and referred to the ER for emergent issues. On 5/5/22, the Program Supervisor called to follow-up about the waitlist and schedule annual GYN appointment for DM, and the earliest appointment available is 7/22/22, appointment is scheduled for 7/22. On 5/19/22 and 5/20/22, Program Administrator contacted clinic for appointment confirmation, still awaiting fax of confirmation. |
05/05/2022
| Implemented |
| 6400.141(c)(10) | On annual physical exam for individual #1 dated 11/16/21 the section referring to communicable disease was left blank and not completed by the physician. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | Program Manager contacted PCP to notify physician that annual physical form had a section referring to communicable disease left blank. PCP stated that a review of records and forms will be performed at individual's upcoming appointment on 6/1/22. |
05/20/2022
| Implemented |
| 6400.144 | The following medications for Individual #1 were not present at the time of inspection:
Ammonium Lactate 12% lotion
Balmex Complete 11.3% cream
Acetaminophen 325 MG tabs
Antacid 750 mg tabs (Tums) | 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.
| Missig medications were delivered as inspection was proceeding on 4/28/22. Medications were requested via reorder form and faxed to pharmacy on 4/26/22 by Program Manager. |
04/28/2022
| Implemented |
| 6400.46(b) | For staff #1 there is no indication that an annual fire safety training was completed by a fire safety expert within the last year. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Fire safety training with fire expert record found after inspection, training conducted on 3/30/21 and 3/29/2022. Record was misfiled. Please see attachment #10, 11 and 12. |
05/09/2022
| Implemented |
| 6400.46(d) | There is no documentation of completed First Aid /CPR certificate for staff #1 | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Staff #1 attended CPR/First Aid training on 12/03/2020. CPR card was misfiled for staff 1 was and located after licensing inspection on 5/9/22. Please see attachment #14. |
05/09/2022
| Implemented |
| 6400.165(b) | The directions for the Ibuprofen 200 MG medication for Individual #1 on the MAR is to "give 2 tablets by mouth every 6 hours" and is no listed as a PRN
However the blister pack states "give 2 tablets by mouth every 6 hours as needed" and is listed as a PRN. This information should be consistent. | A prescription order shall be kept current. | On 4/28/22, Program Manager called pharmacy to get documentation of prescription summary which states the directions per script by physician. On 4/28/22, MAR corrected to state prn for medication. On 3/23/22, pharmacy notified MD of omission of PRN from directions, MD made correction on 4/14/22, a date after MARs were already printed and delivered to Agape. On 4/28/22, MAR was updated to reflect prn status of medication as written on prescription. |
04/28/2022
| Implemented |
| 6400.165(c) | There is no indication that the Balmex Complete 11.3% cream for Individual Dawn Morgan medication is being administered as prescribed as there were no signatures for the month of April 2022 up to the date of administration. | A prescription medication shall be administered as prescribed. | All DSP and administrative staff will be trained on medication administration and documentation on 5/20/22 by Program Administrator and Nurse and were notified of this mandatory training on 5/13/22. Training will encompass all parts of the MAR, coding and signature requirement for medication administration. |
05/12/2022
| Implemented |
| 6400.165(g) | Most recent documented psychotropic medication review for individual #1 occurred on 10/19/21 which as greater than the 90 days as outlined in the regulations. | 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. | Initial appointment was scheduled for January 2022 after 10/19/21; however, it was cancelled by physician¿s office due to physician being out of office. Due to psychiatric waitlist at the time, the initial appointment was rescheduled to 4/7/22 which was attended. Please refer to uploaded document #18 |
05/16/2022
| Implemented |
| 6400.166(a)(13) | The Balmex Complete 11.3% cream for Individual #1 has not been signed off on the MAR for the month of the April 2022 up to the date of the inspection even though the directions state "apply topically to abdomen daily". | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | All DSP and administrative staff will be trained on medication administration and documentation on 5/20/22 by Program Administrator and Nurse and were notified of this mandatory training on 5/13/22. Training will encompass all parts of the MAR, coding and signature requirement for medication administration. |
05/20/2022
| Implemented |