| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.135(c) | The November 2025 Medication Administration Records (MAR) for Individual #1 included an entry for Pioglitazone to be administered as directed. The physician report from 4/16/25 indicates that the medication should be administered for blood glucose levels over 180. Blood glucose levels were checked on 12/1/25 and 12/2/25 and all prior days. The 12/1/25 entry noted that the bloods glucose level was 138 but the medication had been administered. The medication was not administered as prescribed. | A prescription medication shall be administered as prescribed. | 12/8/25 provider was retrained by a med trainer on proper procedures for administering medications. |
12/08/2025
| Implemented |
| 6500.136(a)(7) | Individual #1 is prescribed Quetiapine Fumarate to be administered as "1-2 tabs as needed for increased agitation, do not give routinely" According to the November 2025 Medication Administration Record (MAR) for Individual #1 the medication was administered on 12/1/25 and 12/2/25. The administration documentation on the MAR did not include the number of pills, or dose (1 or 2 tablets) of medication, administered. A count was completed which indicated that the count of medication decreased by two but the dose was not noted on the MAR as required. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | 12/8/25 provider was retrained on proper procedures when administering medications.
((Quetiapine Fumarate was discontinued by PCP -CH 3/13/26)) |
12/08/2025
| Implemented |
| 6500.177(4)(I) | Individual #1 is prescribed Quetiapine Fumarate to be administered as "1-2 tabs as needed for increased agitation, do not give routinely" The medication was administered on 12/1 and 12/2. Staff #1 stated that there is no protocol in place, and they just administer the medication when they note it to be needed. There was no protocol or specific directions for the administration of the medication in the Individual's record as required. | A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition. | Provider retrained on proper procedures when administering medications on 12/8/25. |
12/08/2025
| Implemented |