| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.125(b) | Household member #5's 7/12/23 physical is not dated by the physician. | The physical examination documentation shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | This physical has been returned to the physician to be dated. Awaiting call that it is complete. |
09/30/2023
| Implemented |
| 6500.133(d) | Individual #1's prescription medications are stored in a basket in an unlocked kitchen cabinet. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | Individual's medications have been locked in a locked box. |
09/30/2023
| Implemented |
| 6500.136(b) | Individual #1's 8pm doses of Otezla from 7/27/23 through 7/31/23 were not documented as administered at the time of administration. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | This was a documentation error. Life sharing provider was reminded to ensure that they must initial all medication administrations. Documentation of discussion placed in file. |
09/30/2023
| Implemented |
| 6500.137(a)(4) | Individual #1 has a PRN prescription for Hydroxyzine that is to be administered once daily at bedtime if needed for itching. On 8/1/23, 8/2/23, and 8/7/23 through 8/25/23, this medication was given at 8am instead of at bedtime as prescribed. | Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time. | The MAR was reviewed for accuracy and Life Sharing provider was instructed to ensure medications are given at the time stated on the label. The program specialist will consult the physician to see if medication can be given in the morning as requested by the individual. |
10/15/2023
| Implemented |
| 6500.137(c) | The errors described in 6500.137a4 were not reported in the department's incident management system. | A medication error shall be reported as an incident as specified in § 6500.20(b) (relating to incident report and investigation). | Upon discovery by licensing, medication error was reported in EIM. |
10/15/2023
| Implemented |