| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.166(a)(4) | Individual #1 is prescribed Meloxicam 15mg; take 1 tablet by mouth daily. The name of the medication was not included on the October 2020 medication record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | Meloxicam was added to the appropriate medication log when the error was discovered on 10/08/20. Supportive Living Services (SLS) staff that administer medications at the 2559 East 32nd Street Location will be re-trained on SLS medication administration 15 steps procedure by 11/21/20. Also the SLS 15 steps medication administration procedure will be added to each medication log book for all individuals residing at SLS group home locations by 11/21/20. The following oversight actions will be implemented to prevent and reoccurrence: Residential Manager will review new monthly medication administration logs against current medications being administered to ensure accuracy, Residential Manager will review medication logs weekly and random spot checks will be completed, Residential Manager or designee will review medications when received at every 28 day cycle and compare to medication logs with medications for accuracy. Residential manager will be trained on medication oversight process by 11/21/20. In addition a medication administration refresher training will be completed with all staff and every 2 years thereafter as med admin course is only typically completed for new hires during orientation. Medication administration refresher course will be completed with all agency staff by 06/30/21. |
06/30/2021
| Implemented |
| 6400.166(a)(5) | Individual #1 is prescribed Meloxicam 15mg; take 1 tablet by mouth daily. The strength of the medication was not included on the October 2020 medication record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | Meloxicam and the strength of the medication was added to the appropriate medication log when the error was discovered on 10/08/20. Supportive Living Services (SLS) staff that administer medications at the 2559 East 32nd Street Location will be re-trained on SLS medication administration 15 steps procedure by 11/21/20. Also the SLS 15 steps medication administration procedure will be added to each medication log book for all individuals residing at SLS group home locations by 11/21/20. The following oversight actions will be implemented to prevent and reoccurrence: Residential Manager will review new monthly medication administration logs against current medications being administered to ensure accuracy, Residential Manager will review medication logs weekly and random spot checks will be completed, Residential Manager or designee will review medications when received at every 28 day cycle and compare to medication logs with medications for accuracy. Residential manager will be trained on medication oversight process by 11/21/20. In addition a medication administration refresher training will be completed with all staff and every 2 years thereafter as med admin course is only typically completed for new hires during orientation. Medication administration refresher course will be completed with all agency staff by 06/30/21. |
06/30/2021
| Implemented |
| 6400.166(a)(7) | Individual # 1 is prescribed Meloxicam 15mg; Take 1 tablet by mouth daily. The dose of the medication was not included on the October 2020 medication record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | Meloxicam and the dose of the medication was added to the appropriate medication log when the error was discovered on 10/08/20. Supportive Living Services (SLS) staff that administer medications at the 2559 East 32nd Street Location will be re-trained on SLS medication administration 15 steps procedure by 11/21/20. Also the SLS 15 steps medication administration procedure will be added to each medication log book for all individuals residing at SLS group home locations by 11/21/20. The following oversight actions will be implemented to prevent and reoccurrence: Residential Manager will review new monthly medication administration logs against current medications being administered to ensure accuracy, Residential Manager will review medication logs weekly and random spot checks will be completed, Residential Manager or designee will review medications when received at every 28 day cycle and compare to medication logs with medications for accuracy. Residential manager will be trained on medication oversight process by 11/21/20. In addition a medication administration refresher training will be completed with all staff and every 2 years thereafter as med admin course is only typically completed for new hires during orientation. Medication administration refresher course will be completed with all agency staff by 06/30/21. |
06/30/2021
| Implemented |
| 6400.166(a)(8) | Individual #1 is prescribed Meloxicam 15mg; take 1 tablet by mouth daily. The route of the administration was not included on the October 2020 medication record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | Meloxicam and the route of administration was added to the appropriate medication log when the error was discovered on 10/08/20. Supportive Living Services (SLS) staff that administer medications at the 2559 East 32nd Street Location will be re-trained on SLS medication administration 15 steps procedure by 11/21/20. Also the SLS 15 steps medication administration procedure will be added to each medication log book for all individuals residing at SLS group home locations by 11/21/20. The following oversight actions will be implemented to prevent and reoccurrence: Residential Manager will review new monthly medication administration logs against current medications being administered to ensure accuracy, Residential Manager will review medication logs weekly and random spot checks will be completed, Residential Manager or designee will review medications when received at every 28 day cycle and compare to medication logs with medications for accuracy. Residential manager will be trained on medication oversight process by 11/21/20. In addition a medication administration refresher training will be completed with all staff and every 2 years thereafter as med admin course is only typically completed for new hires during orientation. Medication administration refresher course will be completed with all agency staff by 06/30/21. |
06/30/2021
| Implemented |
| 6400.166(a)(9) | Individual #1 is prescribed Meloxicam 15mg; take 1 tablet by mouth daily. The frequency of administration was not included on the October 2020 medication record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | Meloxicam and the frequency of administration was added to the appropriate medication log when the error was discovered on 10/08/20. Supportive Living Services (SLS) staff that administer medications at the 2559 East 32nd Street Location will be re-trained on SLS medication administration 15 steps procedure by 11/21/20. Also the SLS 15 steps medication administration procedure will be added to each medication log book for all individuals residing at SLS group home locations by 11/21/20. The following oversight actions will be implemented to prevent and reoccurrence: Residential Manager will review new monthly medication administration logs against current medications being administered to ensure accuracy, Residential Manager will review medication logs weekly and random spot checks will be completed, Residential Manager or designee will review medications when received at every 28 day cycle and compare to medication logs with medications for accuracy. Residential manager will be trained on medication oversight process by 11/21/20. In addition a medication administration refresher training will be completed with all staff and every 2 years thereafter as med admin course is only typically completed for new hires during orientation. Medication administration refresher course will be completed with all agency staff by 06/30/21. |
06/30/2021
| Implemented |
| 6400.166(a)(10) | Individual #1 is prescribed Meloxicam 15mg; take 1 tablet by mouth daily. The administration times of the medication was not included on the October 2020 medication record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | Meloxicam and the administration time was added to the appropriate medication log when the error was discovered on 10/08/20. Supportive Living Services (SLS) staff that administer medications at the 2559 East 32nd Street Location will be re-trained on SLS medication administration 15 steps procedure by 11/21/20. Also the SLS 15 steps medication administration procedure will be added to each medication log book for all individuals residing at SLS group home locations by 11/21/20. The following oversight actions will be implemented to prevent and reoccurrence: Residential Manager will review new monthly medication administration logs against current medications being administered to ensure accuracy, Residential Manager will review medication logs weekly and random spot checks will be completed, Residential Manager or designee will review medications when received at every 28 day cycle and compare to medication logs with medications for accuracy. Residential manager will be trained on medication oversight process by 11/21/20. In addition a medication administration refresher training will be completed with all staff and every 2 years thereafter as med admin course is only typically completed for new hires during orientation. Medication administration refresher course will be completed with all agency staff by 06/30/21. |
06/30/2021
| Implemented |
| 6400.166(a)(11) | Individual # 1 is prescribed Meloxicam 15mg; take 1 tablet by mouth daily. The diagnosis or purpose of the medication was not included on the October 2020 medication record. | 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. | Meloxicam was added to the appropriate medication log when the error was discovered on 10/08/20. Supportive Living Services (SLS) staff that administer medications at the 2559 East 32nd Street Location will be re-trained on SLS medication administration 15 steps procedure by 11/21/20. Also the SLS 15 steps medication administration procedure will be added to each medication log book for all individuals residing at SLS group home locations by 11/21/20. The following oversight actions will be implemented to prevent and reoccurrence: Residential Manager will review new monthly medication administration logs against current medications being administered to ensure accuracy, Residential Manager will review medication logs weekly and random spot checks will be completed, Residential Manager or designee will review medications when received at every 28 day cycle and compare to medication logs with medications for accuracy. Residential manager will be trained on medication oversight process by 11/21/20. In addition a medication administration refresher training will be completed with all staff and every 2 years thereafter as med admin course is only typically completed for new hires during orientation. Medication administration refresher course will be completed with all agency staff by 06/30/21. |
06/30/2021
| Implemented |
| 6400.166(a)(12) | Individual # 1 is prescribed Meloxicam 15mg; take 1 tablet by mouth daily. The date and time of medication administration was not included on the October 2020 medication record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration. | Meloxicam was added to the appropriate medication log when the error was discovered on 10/08/20. Supportive Living Services (SLS) staff that administer medications at the 2559 East 32nd Street Location will be re-trained on SLS medication administration 15 steps procedure by 11/21/20. Also the SLS 15 steps medication administration procedure will be added to each medication log book for all individuals residing at SLS group home locations by 11/21/20. The following oversight actions will be implemented to prevent and reoccurrence: Residential Manager will review new monthly medication administration logs against current medications being administered to ensure accuracy, Residential Manager will review medication logs weekly and random spot checks will be completed, Residential Manager or designee will review medications when received at every 28 day cycle and compare to medication logs with medications for accuracy. Residential manager will be trained on medication oversight process by 11/21/20. In addition a medication administration refresher training will be completed with all staff and every 2 years thereafter as med admin course is only typically completed for new hires during orientation. Medication administration refresher course will be completed with all agency staff by 06/30/21. |
06/30/2021
| Implemented |