| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.50(a) | Documentation of the training on The Fatal Five NEPA HCQU Advocacy Alliance, IHRS Corporate Compliance Plan, IHRS HIPAA Privacy and Confidentiality Manual Review, IHRS training on Epi Pen and Generic forms- non certification, and Common medication side effects did not record the length of the trainings as required for those completed in the 2023 training year. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | CEO met with training department to discuss citation and possible corrective measures. It has been determined that the training face sheet will be revised to reflect proper and appropriate information. Individual had the training but the hours were not reflected properly on the face sheet. |
11/30/2024
| Implemented |
| 6400.52(a)(1) | Training records for Staff #1 covering the training year of 1/1/23 to 12/31/23 recorded a total of 14 training hours completed. Staff #1 did not complete the required 24hours of training for the 2023 training year. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | Training file was reviewed and Individual did have the required hours of training. The hours were not reflecting properly on the face sheet. CEO met with training department to discuss citation and possible corrective measures. It has been determined that the training face sheet will be revised to reflect proper and appropriate information. Individual had the training but the hours were not reflected properly on the face sheet. |
11/30/2024
| Implemented |
| 6400.169(a) | The employee training record for 2024 for Staff #1 included two entries for Med Pass 1 and Med Pass 2. The date completed section for both trainings was blank. The Annual Practicum packet for Staff #1 documented the training period to be 1/24/24 to 1/24/25. The form noted two Medication Record Reviews (MRR) completed on 2/24 and 4/24. The MRR were not completed on the six month timeframe as required. The section to record completed medication administration observations was blank. There was no documentation to indicate that the medication administration observation was completed as required in 6/24. There was a trainer signature on the bottom of the packet with no date. The "requalified" section of the form was not checked to indicate that Staff #1 was requalified to administer medications. Staff #1 did not sign the document. Documentation supports that the course renewal requirements were not completed as required to maintain the ability to administer medications. | 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). | Training file was reviewed and Individual did have the proper practicum requirements. Information was not transcribed to the form properly due to oversight. Information was updated and is currently correct. |
11/30/2024
| Implemented |