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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.165(d) | On 3/12/2025 at approximately 11:40am, the following pro re nata medications prescribed to Individual #1 were labeled as "House Stock Medications": QC Pink Bismuth 262mg/15, Acetamin tab 325mg, Antacid Sus Antigas 15mL, Fleet Enema, Geri-Tussin Syp DM 10mL, Ibuprofen tab 200mg, Milk of Magn Sus 1200/15, and Sudogest Tab 30mg. The house stock prescription medications were to be utilized by any individual in the home with a current order for said medication. Additionally, the pharmacy issued medication label did not include administration instructions such as the individual's name, medication dosage, administration route, or frequency of administration. | A prescription medication shall be used only by the individual for whom the prescription was prescribed. | On 3/13/25, the Vice President of Residential and Disability Services retrained the Nurses on regulation 6400.165(d). Medication labels will be completed by 5/16/25. |
05/16/2025
| Implemented |
| 6400.207(5)(III) | On 3/12/2025 at 10:06am, Individual #2's bed contained full bedrails that restricted the movement or function of the individual's body. The agency obtained a prescription for full bed rails with no padding on 6/21/2023. Although the bed rails are prescribed by the medical practitioner, it was revealed through conversations with agency staff that the individual's most current assessment does not address if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual. Individual #2's individual plan last updated 10/29/2024 does not include periodic relief of the device to allow freedom of movement.
On 3/12/2025 at 10:06am, Individual #3's bed contained full bedrails that restricted the movement or function of the individual's body. The agency obtained a prescription for full sided, padded bedrails on 6/21/2023. Although the bed rails are prescribed by the medical practitioner, it was revealed through conversations with agency staff that the individual's most current assessment does not address if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual. Individual #3's individual plan last updated 11/14/2024 does not include periodic relief of the device to allow freedom of movement.
On 3/12/2025 at 10:06am, Individual #4's bed contained full bedrails that restricted the movement or function of the individual's body. The agency obtained a prescription for two half bedrails with no padding on 6/21/2023. Although the bed rails are prescribed by the medical practitioner, it was revealed through conversations with agency staff that the individual's most current assessment does not address if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual. Individual #4's individual plan last updated 11/4/2024 does not include periodic relief of the device to allow freedom of movement.
On 3/12/2025 at 10:06am, Individual #5's bed contained full bedrails that restricted the movement or function of the individual's body. The agency obtained a prescription for two half bedrails with pads and pillow on 6/21/2023. Although the bed rails are prescribed by the medical practitioner, it was revealed through conversations with agency staff that the individual's most current assessment does not address if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual. Individual #5's individual plan last updated 10/29/2024 does not include periodic relief of the device to allow freedom of movement.
On 3/12/2025 at 10:06am, Individual #6's bed contained full bedrails that restricted the movement or function of the individual's body. The agency obtained a prescription for two half bedrails with no padding on 6/21/2023. Although the bed rails are prescribed by the medical practitioner, it was revealed through conversations with agency staff that the individual's most current assessment does not address if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual. Individual #6's individual plan last updated 6/10/2024 does not include periodic relief of the device to allow freedom of movement.
On 3/12/2025 at 10:06am, Individual #7's bed contained full bedrails that restricted the movement or function of the individual's body. The agency obtained a prescription for a bariatric hospital bed on 11/2/2022 and an additional order for a face to face bariatric hospital bed on 2/2/2024. A third order for full side rails with hospital bed was obtained on 3/12/2025 after the violation had been identified by the licensing representative. Although the bed rails are prescribed by the medical practitioner, it was revealed through conversations with agency staff that the individual's most current assessment does not address if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual. Individual #7's individual plan last updated 10/29/2024 does not include periodic relief of the device to allow freedom of movement. | A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Protection from injury during a seizure or other medical condition, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement. | On 3/25/25, the Vice President of Residential and Disability Services retrained the Program Specialists to include documentation of regulation 6400.207(5)(iii) in the annual assessment, along with a physician's order. |
03/25/2025
| Implemented |
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