| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.144 | REPEAT from 9/19/22 annual inspection: The home failed to provide health services to Individual #1 on a few occasions throughout the last year, from September 2022 to September 2023. The following instances described below explain the failures.
Individual #1 saw their physician on 01/05/23 for a 3 month follow up, complaints of knee pain and diarrhea, and their physician recommended blood draws and a stool culture sample. The laboratory technician provided a container for the stool sample on 01/05/23 and was to provide the stool sample by 01/06/23 by 2pm. According to the individual's medical records, the home did not submit the individual's stool sample for testing until 1/9/23. According to medical records, the individual was complaining of diarrhea since 12/21/22.
On 09/13/22, Crisis Intervention was called due to Individual #1 stating they don't feel worthy of being in the residential home or alive. Staff documented Crisis Intervention came out to assess the situation and will send a message to individual #1 psychiatrist to see if the individual can get an earlier appointment or medication change. The individual was not seen by their psychiatrist until 11/14/22. There are no records that the home addressed the individual's suicidal ideations with their psychiatrist, medical professionals, requested any medication reviews, or was seen by medical personnel after 09/13/22 for these suicidal ideations.
Individual #1 saw their therapist on 03/30/23 and was to return on 05/16/23. There is a note that the home contacted the individual's therapist on 05/16/23. The note states the 05/16/23 appointment was cancelled and not completed due to differing appointment times. The record does not record who made the error, the residential home, or if the physician's office called to make the cancelation. The agency confirmed on 09/07/23 that residential staff arrived to the 05/16/23 appointment at a different time than the appointment was scheduled for.
On 01/30/23 the individual's physical therapist ordered hamstring curl with anchored resistance and sitting knee extension with resistance exercises for 2 sets of 10 each, once per day. The home did not produce records that these exercises were complete or refused. The home-produced records that the individual completed therapy exercises until 01/29/23.
According to Individual #1's current, 02/23/23 assessment, the home has assessed the individual to not be able to self-administer their medications (except for Flonase nasal spray and eye drops) and will overdose on medication. The home started working with the individual on a goal to be able to learn their medications (vitamin-D, omeprazole, docusate sodium, cetirizine, risperidone, and lamotrigine) and self-administer them. At the time of the 09/07/23 inspection, the individual was not reassessed to be able to self-administer their medications. However, from March 1st to September 8th, 2023, the home only has records that the individual was self-administering their medications. At the time of the inspection, staff were only documenting that they were administering the individual's weekly ear drops, but Individual #1 was administering all the rest of their medications. The home does not have records of the staff who administered medications daily as the individual was not assessed to be able to complete self-administration.
During the 09/08/23 inspection of the home, Individual #1's fluticasone nasal spray was at the home. The pharmacy issued medication label on the mediations stated it was dispensed from the pharmacy on 08/02/23, included 120 doses, and was to be administered as 2 sprays in each nostril daily. During the onsite inspection, there was barely, if any, medication left in the bottle. The home did not have another bottle of medication available for the individual. The home had indicated that the individual takes this medication independently and accurately. However, the bottle only included 120 doses, and from the time the medication was dispensed from the pharmacy until the time of the onsite inspection, a minimum of 144 doses should have been administered if the individual was administering the medication properly. The staff at the home confirmed the bottle on site was the only bottle of fluticasone spray the individual has been using in the last month. | 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.
| 1. The RN/LPN will ensure that all 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 RN/LPN will ensure that timeframes are met for any health services that have been prescribed or planned for the individual is implemented within the time frame set forth by the ordering medical/licensed personnel.
~The Residential Program Supervisor will ensure that the DSP's are completing proper documentation at doctor's appointments that is clear, concise and complete, leaving no questions unanswered.
~The Program House Supervisor and RN/LPN will ensure that forms and charts are implemented directly after any health services are prescribed to document compliance.
~The RN/LPN will ensure that all scheduled appointments (date, time and location of
appointment) are accurate and that staff are aware as per schedule.
~ The Program Specialist will modify the manner in which goals for self-administering medication is documented. |
10/09/2023
| Implemented |
| 6400.181(e)(12) | Individual #1's current 02/23/23 Assessment doesn't include the recommended programming and services the agency recommends for the individual. The individual's Assessment states: "programming: shadowfax, services: residential, shadowfax, cornerstone, focus." The Assessment does not describe the programming or services recommended, but only lists the names of companies. Each of the companies listed offer multiple programs and services, and the specific programming and services recommended from each company is not included in the individual's assessment. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The Program Specialist will ensure that the annual assessment lists recommended programming and services. |
10/06/2022
| Implemented |
| 6400.181(e)(13)(vii) | Individual #1's current 02/23/23 Assessment doesn't include the current level of abilities to handle monies independently, more specifically the amount of money they can handle independently. The Assessment checks two boxes that state they can handle money above $5 and below $5, does not specify the amount about $5, and states the individual is not financial independent and requires assistance. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| 1. Assessment has been modified to document types of services versus the provider agency. |
10/09/2023
| Implemented |
| 6400.32(r) | The individuals in the home do not have the ability to lock and unlock their bedroom door so that other individuals in the home won't have access to their bedroom once locked. During the 09/08/23 inspection, the home staff reports that the same key operates all the locks to the entrance of the home and all three individuals' bedrooms. Individual #1 had a key to lock and unlock their bedroom door but could also use the same key to operate the locking device on the other two housemate's doors, thus not allowing the other housemates the privacy to lock their bedroom doors.
During the 09/08/23 inspection, Individual #2 did not have a key to lock and unlock their bedroom door. The individual reported they wanted one and have wanted one for some time. Staff in the home report that they are working on getting the individual a locking mechanism for their bedroom. | An individual has the right to lock the individual's bedroom door. | Ensure that each individual has the necessary equipment to lock and unlock their bedroom door. |
12/15/2023
| Implemented |
| 6400.166(a)(5) | According to Individual #1's fluticasone nasal spray, the strength of the medication is 50mcg per spray. The individual's September 2023 medication administration record did not record the strength of the medication, but rather indicated "n/a" (not applicable) as the strength of the medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | The DSP's and House Supervisor will ensure that the MAR has listed all required information. |
10/09/2023
| Implemented |
| 6400.166(b) | REPEAT from 09/19/22 annual inspection: Staff #4 did not record their name and initials on the individual's MAR until 10/13/22 for administering Lamotrigine 150mg to Individual #1 at 8pm on 10/11/22.
At the time of the 09/06/23 inspection, it is unclear who administered Lamotrigine 150mg at 8pm to Individual #1 on 11/12/22. According to the individual's mars: Staff #5 recorded a note that they administered Lamotrigine 150mg to Individual #1 at 8pm on 11/12/22 but was unable to sign the MAR, Staff #6 signed their name for administering Lamotrigine 150mg at 8pm on 11/12/22 to Individual #1, Staff #6 recorded a note at 11:15am on 11/30/22 that they did not administer Lamotrigine on 11/12/22 at 8am but signed the wrong spot, and Staff person #7 signed their name for administering Lamotrigine 150mg at 8am on 11/12/22 to Individual #1.
There are no records if Individual #1 received their prescribed docusate sodium 100mg capsule at 8am on 04/30/23. At this date, the individual was not assessed to be able to self-administer this medication. The individual's MAR was left blank. On 05/14/23 a note was recorded on the individual's MAR that the individual forgot to sign the MAR for their docusate sodium capsule. The name of the staff who administered the medication, ensured the medication was administered, and was supervising the individual was not recorded.
On 07/25/23 Staff #8 documented they administered Murine Ear drops to Individual #1 on 07/06/23 at 8am but did not include their name and initials for administering the medication until 07/25/23.
Staff persons who administered neomycin polymyxin ear drops to the individual at 4pm on 08/04/23, and 8pm on 08/04/23 and 08/05/23, did not sign their name and initials on the individuals MAR immediately after administration. The notes about the lack of MARs state that the staff forgot to sign the MAR but the staff popped the medication from the blister pack; the medication was an ear drop suspension, not a pill. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | HR staff will ensure that the DSP's are aware of the expectations regarding signing for medication at the time of administration. |
10/09/2023
| Implemented |
| 6400.167(a)(1) | Individual #1 is prescribed Blink tears lubricating drops, 1 drop in each eye twice daily. Individual #1 was only administered the drops once on 12/07/22. Staff #5 recorded a note on the individual's MAR on 12/07/22 stating that they signed the MAR as documentation of administering the drops at 8pm but they did not administer the drops. The individual's mars do not record the name and initials of any other staff who administered the second dose of the eye drops on 12/07/22.
On 02/23/23 the home assessed the individual to not be able to self-administer their medications, with the exception of their eye drops and Flonase nasal spray. On 05/14/23 Individual #1 did not receive their prescribed cetirizine 10mg tablet at 8pm. On 05/17/23 Staff #1 recorded a note on the individual's MAR that Individual #1 signed that they administered their cetirizine but the pill was still located in the pill packet. Staff, who are responsible for administering the individual's medication, did not ensure the individual received cetirizine on 05/14/23 at 8pm. | Medication errors include the following: Failure to administer a medication. | HR stall will ensure that the DSP's are aware of the expectations regarding administering medication and reporting medication errors. |
10/09/2023
| Implemented |
| 6400.167(b) | The medication errors described in this report were not documented in the individuals record, follow up action wasn't taken, and the prescriber's response wasn't sought, except for the medication errors reported on 04/12/23 and 05/14/23. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | The RN/LPN will ensure that med errors, including follow up action and the prescriber's response is adequately documented. |
10/09/2023
| Implemented |
| 6400.167(c) | The medication errors described in this report were not reported to the Department of Human Services as an incident as specified in § 6400.18(b), except for the medication errors reported on 04/12/23 and 05/14/23. | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | RN/LPN will ensure that med errors are reported on EIM as per the IM bulletin. |
10/09/2023
| Implemented |