| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.165(c) | Individual #1 is prescribed Sleep Minis 5 MG THC, 1 MG CHD, 1 MG CBN with directions to take one piece daily. The January 2024 Medication Administration Record states to take two pieces at 8 AM and one piece at 4 PM for anxiety. The medication is not being administered as prescribed.
Individual #1 is prescribed Relieva Refresh Eye Drops with directions to instill one or two drops into the affected eyes as needed. The January 2024 Medication Administration Record states to instill eye drops in both eyes four times a day for dry eyes. This medication is not being administered as prescribed. | A prescription medication shall be administered as prescribed. | During licensing inspection, it was found that Individual #1 is prescribed Sleep Minis 5 MG THC, 1 MG CHD, 1 MG CBN with directions to take one piece daily. The original container does not read to ¿only take on piece daily¿, rather it reads to take one piece but does not specify how many can be taken. The January 2024 Medication Administration Record states to take two pieces at 8 AM and one piece at 4 PM for anxiety. The MAR reads correctly as shown on the attached February 2024 MAR and does not go against what is on the original container. TTSR will seek to get clarification from the prescriber and request that the original container be more specific as to what times the gummies and be administered.
Individual #1 is prescribed Relieva Refresh Eye Drops with directions to instill one or two drops into the affected eyes as needed. The January 2024 Medication Administration Record states to instill eye drops in both eyes four times a day for dry eyes. This medication is not being administered as prescribed.
On 2/5/2024, after discussion with PCP, the Relieva refresh eye drops were discontinued from Individual¿s routine Medication Administration due in large part to the Individual refusing to use them. It was told to the doctor that Individual would not allow staff to properly administer the eye drops as prescribed and the Individual chose to have the eye drops discontinued.
By signing the attached document, Site Supervisor acknowledges that she was retrained on regulation 165(c) on 2/19/2024and that she will ensure that all medications will be administered as prescribed. |
02/19/2024
| Implemented |
| 6400.166(a)(7) | Individual #1 is prescribed Otezla 30 MG Tablet and Silver Birch CBD Mixed Fruit Gummies 25 MG CBD. The dose was missing for both medications on the January 2024 Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | During annual licensing inspection it was learned that Individual #1 is prescribed Otezla 30 MG Tablet and Silver Birch CBD Mixed Fruit Gummies 25 MG CBD. The dose was missing for both medications on the January 2024 Medication Administration Record.
For February Medication Administrations, TTSR Site Supervisor wrote in the dosage for the Otezla 30 mg. (twice daily) and Silver Birch 25mg (taking twice daily).
Attached in the MAR for February that shows the additions of the dosages. Also attached is a sign off document that acknowledges that Site Supervisor received a retrain on regulation 166(a)(7) and that she will be tasked with ensuring that all MARS match exactly with what is on the original containers for all prescribed medications. |
02/19/2024
| Implemented |
| 6400.166(a)(9) | Individual #1 is prescribed Therapeutic Dandruff Shampoo with directions to apply topically to scalp, lather, let sit for five minutes and rinse for dandruff - alternate shampoos and administer every other day. The January 2024 Medication Administration Record states to apply topically to scalp daily, lather, let sit for five minutes and rinse for dandruff.
Individual #1 is prescribed Calcipotrien Cre 0.005% with directions to apply to skin twice a day with halobetasol for dermatoses as needed. The January 2024 Medication Administration Record states to apply to skin twice a day with halobetasol for dermatoses.
Individual #1 is prescribed Betamethasone Dipropionate Lotion 0.05 % with directions to apply topically 1 application to the skin on the scalp in the morning for dermatoses as needed. The January 2024 Medication Administration Record states to apply topically 1 application to the skin on the scalp in the morning for dermatoses. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | During licensing inspection, it was found that 3 of Individual#1¿s medications did not match exactly with what was written in the Individual¿s MAR. There were discrepancies in that the original containers administration frequency differed from what was written in the MARS. The three medications were as follows:
¿ Therapeutic Dandruff Shampoo
¿ Betameth Dip Lot
¿ Calcipotrien
On 1/31/2024, TTSR Residential Coordinator contacted the pharmacy for clarification and to request that a new MAR be produced and sent to TTSR so that the MAR matches exactly with what is written on the original container for all of Individual #1¿s medications. On 2/1/2024, TTSR received the newly revised MAR and the MAR was compared to the original containers for all medications. Attached to POC is a copy of the newly revised MAR.
TTSR Residential Coordinator will be tasked with reviewing all medications received weekly by the pharmacy and will ensure that the original containers match exactly with what is written in the MARs to prevent confusion and errors for any certified staff who administers medications regularly. Residential Coordinator was retrained on regulation 166(a)(9) and will review all medications received weekly by the pharmacy and will ensure that the original containers match exactly with what is written in the MARs. |
02/01/2024
| Implemented |