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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.166(a)(11) | Individual #1 is prescribed the following medications that do not include the diagnosis or purpose on the December 2023 Medication Administration Record: Divalproex Sod ER 500 MG Tablet , Fluticasone 50 MCG Nasal Spray , Lokelma 10 Gram Power Packet, Montelukast Sod 10 MG Tablet , One day multi-vitamin tab, Opcon-A Eye Drops, Pantoprazole 20 MG, Quetiapine Fumarate 100 MG Tab, Quetiapine Fumarate 400 MG Tab, Vitamin D2 50,000unt Cap. | 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. | The community home nurses have ensured that a diagnosis or purpose has been included in the medication record for each individual who has any prescription medication or treatment administered, including pro re nata. Completed 12/19/2023 |
12/19/2023
| Implemented |
| 6400.207(5)(III) | On 12/13/23, at 12:28 PM, Individual #2 had full bed rails that restrict the movement or function of their body. | A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Protection from injury during a seizure or other medical condition, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement. | Individual #2 was given a physician¿s order for the use of a hospital bed with side rails for safety and protection from injury, secondary to their diagnoses of cerebral palsy and seizure disorder. Individual #2 can and would have their side rails disengaged/lowered by a staff person upon individual #2¿s indication. Individual #2¿s plan allows for periodic relief of the side rails for freedom of movement. |
01/14/2024
| Implemented |
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