| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.33(a) | Individual #1 was not provided prescribed psychotropic medications on at least six different occasions between 3/29/15-10/25/2015. In addition, she was given medications that were not prescribed and had fourteen occurrences of medications not logged in the Medication Administration Record. During 3/29/15-10/25/2015, individual #1 had six psychiatric hospitalizations following medication not provided as prescribed, culminating in neglect. | An individual may not be neglected, abused, mistreated or subjected to corporal punishment. | PAHrtners residential staff will receive training on abuse and the failure to administer medications as neglect conducted by an outside agency, within 30 days of receipt of this plan of correction. All staff that administer medications will receive training on the required follow up when an Individual refuses a medication or when a staff fails to administer medications by a DPW train the trainer. The Program Specialist or designee will conduct a monthly audit of all medications prescribed against all medications available for administration starting within 30 days of receipt of this plan of correction. The Program Specialist or designee will meet with the pharmacy consultant to ensure that prescribed medication is delivered as needed without fail, within 30 days of receipt of this plan of correction. A review of the electronic medication administration records will be conducted daily by the house manager or designee to ensure that if any medications are not administered and or refused by Individuals that the primary care physician is notified with appropriate documentation. |
03/23/2016
| Implemented |
| 6400.143(a) | On 3/29/2015 Individual #1 refused medication. There was no refusal plan in place. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Refusal plan was developed in August 2015, all staff administering medication were notified that when an individual refuses medication they are to make a note in the EMR system, discuss the reason why the individual refused their medication, counsel the individual on the possible results of refusing medication and document in individuals progress note. Documentation of refusal plan for individual #1 will submitted. Staff training on the administration of medication will be updated for all staff that administer medications, within 30 days of receipt of this plan of correction. SW 1.24.17 |
02/23/2016
| Implemented |
| 6400.144 | Individual #1 was not given medications as prescribed by her physician on at least six different days between 3/29/15-10/24/15. | 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.
| PAHrtners residential staff will receive training on abuse and the failure to administer medications as neglect conducted by an outside agency, within 30 days of receipt of this plan of correction. All staff that administer medications will receive training, by a DPW train the trainer within 30 days of receipt of this plan, on medication administration protocol. |
03/23/2016
| Implemented |
| 6400.163(a) | On 9/13/15 Individual # 1 was given medication ( loratadine 10 mg., lamotrigine 25 mg., and 100 mg. ) that was not prescribed. | Prescription medications shall only be used by the individual for whom the medication was prescribed. | All staff that administer medications will receive training, by a DPW train the trainer within 30 days of receipt of this plan, regarding medication administration protocol including how to ensure that medication being administered is only being administered to the person it is prescribed to and how to pack medications to the correct individuals when going off site. |
03/23/2016
| Implemented |
| 6400.164(a) | A review of the computer medication logs from 3/29/15 to 10/24/15 for individual # 1 revealed that on 6 different days at least one and sometimes as many as 3 medications were not administered ( Clonazepam, Topamax, and Venlafaxine ) | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | All staff that administer medications will receive training on the required follow up when an Individual refuses a medication or when a staff fails to administer medications by a DPW train the trainer within 30 days of receipt of this plan. When an individual refuses their medication staff will counsel the individual and document in the individual¿s progress notes. A review of the electronic medication administration records will be conducted daily by the house manager or designee to ensure that if any medications are not administered and or refused by Individuals that the primary care physician is notified with appropriate documentation. When staff fail to administer medication program specialist will meet with staff to review the incident, review procedures and document that the meeting with staff took place. |
03/23/2016
| Implemented |
| 6400.164(b) | A review of the computer medication log from the period of 3/29/15-10/24/15 indicated about 14 occurrences of medication given to individual # 1 were not logged-in. | The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. | All staff that administer medications will receive training, by a DPW train the trainer within 30 days of receipt of this plan, regarding medication administration protocol including documentation (log-in) of medication administrations. |
03/23/2016
| Implemented |