Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.112(c) | The fire drill records for the drills conducted on 12/20/2022 at 5:00pm and 2/8/2023 at 4:09pm did not indicate the total time it took for evacuation. These records indicated the time the fire drill concluded but they did not indicate the exact number of minutes and seconds it took to evacuate. [Repeat violation: 12/7/2022, et al.] | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | The fire drill records for the drills conducted on 12/20/2022 at 5:00pm and 2/8/2023 at 4:09pm did not indicate the total time it took for evacuation. These records indicated the time the fire drill concluded but they did not indicate the exact number of minutes and seconds it took to evacuate. |
12/31/2023
| Implemented |
6400.141(c)(1) | Individual #2's annual physical examination, completed on 9/28/2023, does not include a review of the individual's previous medical history. This section was left blank on the physical examination form. | The physical examination shall include: A review of previous medical history. | The BLARS nursing staff will reach out to individual #2¿s PCP and request that he complete an addendum or otherwise comment on the area that was blank on the physical examination (previous medical history). The second option will be that the BLARS Lead Nurse populate the ¿previous medical history¿ section and have the PCP review and sign off and date the physical form (as an addendum). |
12/31/2023
| Implemented |
6400.141(c)(4) | Individual #1's physical examination, completed on 5/16/2023, does not include a hearing screening. This section was omitted on the physical examination form. Individual #2's annual physical examination, completed on 9/28/2023, does not include vision and hearing screening. These sections were left blank on the physical examination form. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | The BLARS nursing staff will reach out to individual #1¿s and #2¿s PCP and request that he complete an addendum or otherwise comment on the area that was blank on the physical examination (hearing screening). The second option will be that the BLARS Lead Nurse populate the ¿hearing screening¿ section and have the PCP review and sign off and date the physical form (as an addendum). |
12/31/2023
| Implemented |
6400.141(c)(6) | Individual #1's physical examination, completed on 5/16/2023 does not include a tuberculin skin test by Mantoux method. This section was omitted on the physical examination form. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | The BLARS nursing staff will reach out to individual #1¿s PCP and request that a Mantoux be completed as soon as possible; the target date is 12/31/23. |
12/31/2023
| Implemented |
6400.141(c)(7) | Individual #1's physical examination, completed on 5/16/2023, does not include a gynecological examination, breast examination, or Pap test. Documentation of this most recent examination was not obtained by the provider prior to Individual #1's admission. | 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. | The BLARS nursing staff will reach out to individual #1¿s PCP and request that he complete an addendum or otherwise comment on the area that was blank on the physical examination (gynecological examination, breast examination, or Pap test). |
12/31/2023
| Implemented |
6400.141(c)(10) | Individual #1's physical examination, completed on 5/162023, does not indicate if the individual is free of all communicable disease or specific precautions that must be taken to prevent spread of the disease to other individuals. This section was omitted from the physical examination form. Individual #2's annual physical examination, completed on 9/28/2023, does not indicate if the individual is free of all communicable disease or specific precautions that must be taken to prevent spread of the disease to other individuals. This section was left blank on the physical examination form. | 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. | The BLARS nursing staff will reach out to individual #1 and #2¿s PCP and request that he complete an addendum or otherwise comment on the area that was blank on the physical examination (free of all communicable diseases). The second option will be that the BLARS Lead Nurse populate this section and have the PCP review and sign off and date the physical form (as an addendum). |
12/31/2023
| Implemented |
6400.141(c)(11) | Individual #2's annual physical examination, completed on 9/28/2023, does not include an assessment of the individual's health maintenance needs. This section was left blank on the physical examination form. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The BLARS nursing staff will reach out to individual #2¿s PCP and request that he complete an addendum or otherwise comment on the area that was blank on the physical examination (assessment of the individual¿s health maintenance needs). The second option will be that the BLARS Lead Nurse populate this section and have the PCP review and sign off and date the physical form (as an addendum). |
12/31/2023
| Implemented |
6400.141(c)(12) | Individual #2's annual physical examination, completed on 9/28/2023, does not include the physical limitations of the individual. This section was left blank on the physical examination form. [Repeat violation: 12/7/2022, et al.] | The physical examination shall include: Physical limitations of the individual. | The BLARS nursing staff will reach out to individual #2¿s PCP and request that he complete an addendum or otherwise comment on the area that was blank on the physical examination (physical limitations of the individual). The second option will be that the BLARS Lead Nurse populate this section and have the PCP review and sign off and date the physical form (as an addendum). |
12/31/2023
| Implemented |
6400.141(c)(14) | Individual #1's physical examination, completed on 5/16/2023, does not include medical information pertinent to diagnosis and treatment in case on an emergency. This section was omitted from the physical examination form. [Repeat violation: 12/7/2022, et al.] | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The BLARS nursing staff will reach out to individual #1¿s PCP and request that he complete an addendum or otherwise comment on the area that was blank on the physical examination (medical information pertinent to diagnosis and treatment in case of an emergency). The second option will be that the BLARS Lead Nurse populate this section and have the PCP review and sign off and date the physical form (as an addendum). |
12/31/2023
| Implemented |
6400.141(c)(15) | Individual #1's physical examination, completed on 5/16/2023, does not include special instructions for the individual's diet. This section was omitted from the physical examination form. Individual #2's annual physical examination, completed on 9/28/2023, does not include special instructions for the individual's diet. This section was left blank on the physical examination form. | The physical examination shall include:Special instructions for the individual's diet. | The BLARS nursing staff will reach out to individual #1¿s and #2¿s PCP and request that he complete an addendum or otherwise comment on the area that was blank on the physical examination (special instructions for the individual¿s diet). The second option will be that the BLARS Lead Nurse populate this section and have the PCP review and sign off and date the physical form (as an addendum). |
12/31/2023
| Implemented |
6400.166(a)(4) | On 11/29/2023 at 10:45am, it was discovered that Hydroxyz Pam Cap 25mg, take 1 capsule daily as needed for anxiety, prescribed to Individual #2, did not include the name of the medication on the November 2023 medication administration record. This medication was omitted entirely from the November 2023 medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | Regarding individual #2, a new MAR will be made which will separate his daily dose of the medication from the PRN order that was prescribed. On 12/5/23, the BLARS Nurse Lead communicated with the pharmacy; moving forward a new MAR will be received every month for the PRN dose of this medication. |
12/31/2023
| Implemented |
6400.166(a)(5) | On 11/29/2023 at 10:46am, it was discovered that Hydroxyz Pam Cap 25mg, take 1 capsule daily as needed for anxiety, prescribed to Individual #2, did not include the strength of the medication on the November 2023 medication administration record. This medication was omitted entirely from the November 2023 medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | Regarding individual #2, a new MAR will be made which will indicate the name and strength of medication. On 12/5/23, the BLARS Nurse Lead communicated with the pharmacy; moving forward a new MAR will be received every month for the PRN dose of this medication; the name and strength of the medication will obviously be listed on the MAR. |
12/31/2023
| Implemented |
6400.166(a)(6) | On 11/29/2023 at 10:47am, it was discovered that Hydroxyz Pam Cap 25mg, take 1 capsule daily as needed for anxiety, prescribed to Individual #2, did not include the dosage form of the medication on the November 2023 medication administration record. This medication was omitted entirely from the November 2023 medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | Regarding individual #2, a new MAR will be made which will indicate the name and dosage form of the medication. On 12/5/23, the BLARS Nurse Lead communicated with the pharmacy; moving forward a new MAR will be received every month for the PRN dose of this medication; the name and dosage form of the medication will obviously be listed on the MAR. |
12/31/2023
| Implemented |
6400.166(a)(7) | On 11/29/2023 at 10:48am, it was discovered that Hydroxyz Pam Cap 25mg, take 1 capsule daily as needed for anxiety, prescribed to Individual #2, did not include the dosage of the medication on the November 2023 medication administration record. This medication was omitted entirely from the November 2023 medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | Regarding individual #2, a new MAR will be made which will indicate the name and dosage of medication. On 12/5/23, the BLARS Nurse Lead communicated with the pharmacy; moving forward a new MAR will be received every month for the PRN dose of this medication; the name and dosage of the medication will obviously be listed on the MAR. |
12/31/2023
| Implemented |
6400.166(a)(8) | On 11/29/2023 at 10:49am, it was discovered that Hydroxyz Pam Cap 25mg, take 1 capsule daily as needed for anxiety, prescribed to Individual #2, did not include the route of administration on the November 2023 medication administration record. This medication was omitted entirely from the November 2023 medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | Regarding individual #2, a new MAR will be made which will indicate the name and route of medication. On 12/5/23, the BLARS Nurse Lead communicated with the pharmacy; moving forward a new MAR will be received every month for the PRN dose of this medication; the name and route of medication will obviously be listed on the MAR. |
12/31/2023
| Implemented |
6400.166(a)(9) | On 11/29/2023 at 10:50am, it was discovered that Hydroxyz Pam Cap 25mg, take 1 capsule daily as needed for anxiety, prescribed to Individual #2, did not include the frequency of administration on the November 2023 medication administration record. This medication was omitted entirely from the November 2023 medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | Regarding individual #2, a new MAR will be made which will indicate the name and frequency of medication. On 12/5/23, the BLARS Nurse Lead communicated with the pharmacy; moving forward a new MAR will be received every month for the PRN dose of this medication; the name and frequency of medication will obviously be listed on the MAR. |
12/31/2023
| Implemented |
6400.166(a)(10) | On 11/29/2023 at 10:51am, it was discovered that Hydroxyz Pam Cap 25mg, take 1 capsule daily as needed for anxiety, prescribed to Individual #2, did not include the administration time on the November 2023 medication administration record. This medication was omitted entirely from the November 2023 medication administration record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | Regarding individual #2, a new MAR will be made which will indicate the name and administration times of medication. On 12/5/23, the BLARS Nurse Lead communicated with the pharmacy; moving forward a new MAR will be received every month for the PRN dose of this medication; the name and administration times of medication will obviously be listed on the MAR. |
12/31/2023
| Implemented |
6400.166(a)(11) | On 11/29/2023 at 10:52am, it was discovered that Hydroxyz Pam Cap 25mg, take 1 capsule daily as needed for anxiety, prescribed to Individual #2, did not include the diagnosis or purpose of the medication on the November 2023 medication administration record. This medication was omitted entirely from the November 2023 medication administration record. [Repeat violation: 12/7/2022, et al.] | 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. | Regarding individual #2, a new MAR will be made which will indicate the name and diagnosis or purpose for the medication, including pro re nata of medication. On 12/5/23, the BLARS Nurse Lead communicated with the pharmacy; moving forward a new MAR will be received every month for the PRN dose of this medication; the name and diagnosis or purpose for the medication, including pro re nata of medication will obviously be listed on the MAR. |
12/31/2023
| Implemented |