| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.162(b)(2)(ii) | 162bii: Staff #1 administered Vicks Vapor rub, apply topically to affected area daily as needed for congestion to Individual #1 on 6/9/24. Staff #1 administered Nysytatin Pow 10000, apply topically to affected area twice daily as needed for other (rash) to individual #1 on 6/9/24. Staff #1 received the additional required trainings to administer the 2 topical medications (Vicks Vapor rub and Nysytatin Pow) | A prescription medication that is not self-administered shall be administered by one of the following: A person who has completed the medication administration course requirements as specified in § 6400.168 (relating to medication administration training) for the administration of the following: Topical medications. | Medication Administration Trainer was trained by a Registered Nurse to administer eye, nose and eardrop medications. Documentation of this training was placed in employee file. Staff #1 was trained by the Medication Administration Trainer for eye, nose and ear-drop medications on 7/3/2024. |
07/05/2024
| Implemented |
| 6400.162(b)(2)(iii) | Staff #1 administered Fluticasone Prop 50 MCG spray, administer 2 sprays into nostril in the morning to Individual #1 at 8am on 6/9/24 and 6/10/24.There was no documentation that Staff #1 received the additional required trainings to administer the nasal medication. | A prescription medication that is not self-administered shall be administered by one of the following: A person who has completed the medication administration course requirements as specified in § 6400.168 (relating to medication administration training) for the administration of the following: Eye, nose and ear drop medications. | Medication Administration Trainer was trained by a Registered Nurse to administer eye, nose and eardrop medications. Documentation of this training was placed in employee file. Staff #1 was trained was Medication Administration Trainer for eye, nose and ear-drop medications on 7/3/2024. |
07/05/2024
| Implemented |
| 6400.163(h) | At the time of the inspection, located on the top shelf of the medication closet where Individual#1's medications were also stored were 2 bottles of Lidocaine Viscous SOLN, swish and spit 15 ml as needed for pain, moderate or pain severe. The medication was not listed on the June Medication Administration Record (MAR). The agency provided the licensing representative documentation that medication was discontinued on 5/29/24. Also, located on the top shelf of this medication closet where Individual#1's medications were stored was a bottle of Cephalexin 500 mg capsule, take 1 capsule by mouth three times a day for 7 days. The pharmacy label on the bottle documented the date filled of 4/10/24 with the QTY of 21. The bottle had 10 pills remaining in it. The medications remained with the individual's medications and were not disposed of properly. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Medications that were discontinued were removed from the home and disposed of through a local pharmacy. |
07/05/2024
| Implemented |
| 6400.165(c) | At the time of the inspection, located on the top shelf of the medication closet where Individual#1's medications were also stored was a bottle of Cephalexin 500 mg capsule, take 1 capsule by mouth three times a day for 7 days. The pharmacy label on the bottle documented the date filled of 4/10/24 with the QTY of 21. The bottle had 10 pills remaining in it. The medication was not administered as prescribed. | A prescription medication shall be administered as prescribed. | It was determined that the individual was on a family visit for the days that she did not take the prescribed medications. Staff were retrained on ensuring medications are stored properly and sent with the individual on a home visit as required. Individual was educated regarding the important of taking medications as prescribed. |
07/05/2024
| Implemented |
| 6400.166(a)(11) | Individual #1's June 2024 Medication Administration Record (MAR) did not include the diagnosis or purpose for the following medications: Sertraline, Divalproex ER, Topiramate, Triamcinolone CRE, Fluticasone Prop, and Prednisone. | 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. | The Medication Administration Record was corrected to reflect the diagnoses and purposes. |
07/05/2024
| Implemented |
| 6400.169(a) | A staff person who has successfully completed a Department-approved medication administration course, including the course renewal requirements, may administer medications, injections, procedures, and treatments. The departments medication administration training program annual practicum requirements are two Mediation Administration Record (MAR)Reviews Completed within expected time frame in 1 year period (1 observation every 6 months), and Two Medication Observations Completed within expected time frame in 1 year period (1 observation every 6 months). Staff #1 original qualification date is 10/22/23. Medication Administration record (MAR) review was done on 1/24 and Medication Administration observations was done on 5/24. Staff medication administration training is not being conducted as required by the medication administration training course. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Staff #1 was reassigned the medication administration training course and told she could not pass medications until the course was successfully completed. |
07/05/2024
| Implemented |