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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The window in individual #1's bedroom, located behind the bed, had blinds that were broken in 3 different spots.
Also, at the time of the unannounced inspection, the smoke alarm in individual #1's bedroom was consistently beeping, meaning a battery change was needed. Staff #2 who was present stated, "I didn't notice" and individual #1 was in bed trying to sleep. This was unsafe and most likely disruptive to individual #1's attempt to rest/sleep. Individual #1 is nonverbal. | Floors, walls, ceilings and other surfaces shall be in good repair. | The smoke detector battery on Individual #1s bedroom was changed on 3-1-24 by the Manager of Maintenace and the window blind was repaired on 3-1-24 by Manager of Maintenance .
The Director of Residential Services provided retraining to all staff and management in this specific home on 5-17-2024 regarding the regulation 6400.67(a) referencing floors, walls and ceilings should be in good repair. The retraining specifically addressed all blinds/screens/windows should be in good repair. |
05/17/2024
| Implemented |
| 6400.76(a) | Individual #1's wheelchair's right arm rest was taped with clear packaging tape and a new one is needed. The wheelchair was ordered by the PCP office at the 11/06/2023 appointment; but the provider never submitted orders until 3/01/2024 and again on 3/27/24. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The wheelchair Individual #1 was utilizing on 3-1-2024 was removed from the home by Program Manager on 4-11-2024. Individual #1 has another wheelchair that is clean, sturdy and nonhazardous and is now being utilized by Individual #1.
Program Specialist Lisa Moose and Program Manager were retrained by Director of Residential on regulation 6400.76a referencing furniture and equipment in individual bedrooms and family living areas shall be nonhazardous, clean and sturdy on 5-17-2024.
The order for a new wheelchair for Individual #1 was sent on 3-27-2024 to insurance. It was declined by insurance on 5-1-2024. |
05/17/2024
| Implemented |
| 6400.144 | Individual #1 has physical orders for range of motion exercises to be completed twice daily due to individual #1's diagnosis of quadriplegia; however, there is no documentation showing that these exercises are being completed twice daily as ordered.
On 11/22/24 PCP saw individual #1 for a pressure ulcer and ordered DME equipment that was not ordered by the provider. The after-visit summary states under the "Done today" section of the After-visit summary, "DME Supply-other equipment for pressure injury of left buttock- stage 1". Staff #2 went back to the PCP's office on 2/28/24 (3 months later) to request another copy of the DME orders. Per interviews and documentation review, there was a lack of communication between Staff #1 and Staff #2 which resulted in the DME equipment not being ordered until 3/1/2024 and again on 3/27/2024. | 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.
| The Director of Residential, , retrained Lisa Moose, Program Specialist, on 5-17-2024 regarding maintaining current records in the individuals file and removing all older or discharged records.
The Director of Residential, , retrained Lisa Moose, Program Specialist, on 5-17-2024 regarding the current policy of Managing Medical Appointments. This states that The Program Specialist is responsible for ensuring the implementation of any changes to the individuals services. For example, an individual has a new repositioning protocol. The Program Specialist will create the health and safety protocol, add the protocol to daily documentation for tracking, and provide the protocol training materials to the Program Supervisor and Program Manager to ensure staff training on the new protocol. This also states about the after-visit summary being reviewed within 24 hours of it being received. Any staff/management found to be in violation with this policy will receive progressive discipline.
The Director of Residential, retrained all Program Specialists on 5-17-2024 regarding the regulation 6400.144 referencing 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. |
05/17/2024
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.144 | On 2/17/17, Patricia Lehman did not receive the 8pm dose of Seroquel XR, Nitrofur Mac, Vitamin C, Bacitracin, and Sertraline. The medications were not administered.
According to the medication log, Vitamin C Tab was not administered to Patricia on 3/4/17. There were no initials on the medication log and no explanation on the back of the log.
On 3/30/17, according to the EIM report (8296795) Levothyroxine was not administered to Patricia. The blister pack and medication log were initialed but the medication was still in the blister pack.
| 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.
| Staff have been retrained in the importance of following proper medication administration procedures. The staff who were involved with the failure to administer medications as order were required to develop a plan on how they will specifically administer the medications as prescribed to avoid an error.
The medication on 3/4/17 was administered to Ind #1 but they failed to initial the medication log indicating the medication had been given. Staff have since clarified on the medication log. Disciplinary action was taken with this staff and the medication policy was reviewed with her on 5/19/17 by Lee Prange, Clinical Manager/Medication Trainer. |
05/19/2017
| Implemented |
| 6400.164(a) | On March 2, 2017, Levothyroxine 50mcg was administered to Individual #2. The time of administration was not documented on the medication log. On March 3, 2017 and March 6, 2017, Ventolin HFA 90mcg Inhaler was administered to Individual #2. According to the log, it¿s to be administered every 4 hours as needed. The log did not include a time of administration. | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | The staff who gave the medication failed to document the time of administration. This staff has since documented the time and has received disciplinary action as well as additional training which occurred on 5/19/17, by clinical manager/med trainer Lee Prange. The staff who failed to document the time of administration for the Ventolin FHA put the time frame in the wrong place. This staff is no longer employed by Excentia and therefore corrective action with that staff is not possible. Excentia teaches all staff to place a time in the box with their initials for medications that need to be administered in this manner. This procedure was reviewed with all med trained staff as well. |
05/19/2017
| Implemented |
| 6400.164(b) | The March 7, 2017 medication log indicated Staff #1 administered the 8pm dose of Seroquel and Nitrofur. According to the back of the medication log, Staff #1 indicated he/she signed for the 3/7/17 medications by mistake and meant to initial the 3/8/17 log. Staff #2 indicated on the back of the medication log that he/she administered the 8pm medications on 3/7/17. Staff #2 did not log the medications immediately after administration. | The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. | Staff #2 received disciplinary action for failing to follow medication procedures and document immediately upon administration. Retraining on the medication policy was also reviewed with this staff by Lee Prange, Clinical manager/medication trainer on 5/19/17. The proper procedure for logging medication administration was also reviewed with all staff. |
05/19/2017
| Implemented |
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