| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.144 | Medication SENNA-PLUS TAB is listed on individual #2 MAR and is not being administered as prescribed, Individual has not been given this prescribed medication since 09/22/2023. (No documentation provided as to why this medication is not being administered and no refills provided) (The error was not documented and not placed in (HCSIS), this is and should be reported as neglect). {REPEATED NON-COMPLIANCE 4/11/2023} | 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.
| This has been reported in HCSIS as neglect and certified investigation is being conducted.
The medication was restarted on October 16 after the agency nurse contacted Tarrytown pharmacy to clear up confusion with the Senna Plus Tabs and Fiberlax Tabs. The initial order to discontinue the fiberlax medication was sent to Tarrytown Pharmacy from the doctor on September 28, 2023. A meeting was held between Tarrytown Pharmacy and the agency nurse on October 25, 2023 to find out why it took 18 days for the pharmacy to discontinue the medication from MAR. It was discovered that they overlooked the order and had it corrected. Due to the doctor's discontinuation order being overlooked, the pharmacy thought that the orders were an error because both medications addressed constipation for the individual and thought it was too much medication, therefore the Senna Plus medication was not sent. The fiberlax tabs was then discontinued and removed from MAR on October 16, 2023 per doctor's orders. The Senna Plus was kept on MAR and the individual started taking the medication October 16, 2023. |
12/20/2023
| Not Accepted |
| 6400.18(a)(5) | Medication FIBER-LAX TAB 625 mg is listed on the individual #2 MAR but not in the home, this medication has not been administered to the individual since 10/01/2023 or longer. (The error was not documented and not placed in (HCSIS), this is and should be reported as neglect). | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Neglect.
| EIM report was submitted on December 20 by the Risk Incident Manager and certified investigation is being conducted. |
12/20/2023
| Not Accepted |
| 6400.165(b) | Medication FIBER-LAX TAB 625 mg is listed on the individual #2 MAR but not in the home, this medication has not been administered to the individual since 10/01/2023 or longer. (The error was not documented and not placed in (HCSIS), this is and should be reported as neglect). | A prescription order shall be kept current. | The medication was discontinued and removed from MAR on October 16, 2023 per doctor's orders. The initial order to discontinue the medication was sent to Tarrytown Pharmacy from the doctor on September 28, 2023. A meeting was held between Tarrytown Pharmacy and the agency nurse on October 25, 2023 to find out why it took 18 days for the pharmacy to discontinue the medication from MAR. It was discovered that they overlooked the order and had it corrected. |
10/16/2023
| Not Implemented |
| 6400.165(c) | Medication FLUOXETINE CAP 20mg was not administered to individual #2 on 10/12/2023. | A prescription medication shall be administered as prescribed. | This was corrected on October 13 - there was no medication error because the medication did not arrive from pharmacy on October 12 and the nurse prematurely approved the order in our MAR before the medication arrived. We have a letter from the pharmacy that indicates the medication started on October 13 after arriving to PAHrtners. See attachment 13 |
10/13/2023
| Not Implemented |