| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.71 | Individual #1's bedroom and the spare bedroom did not have emergency numbers on or near the telephones. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| This citation was corrected the same day 7/14/15. The Program Manager/Coordinator will ensure that emergency numbers are on all phones. The monthly safety inspection form was revised on 7/22/15 to include a section to verify that emergency numbers are labeled on all phones. The Program Manager/Coordinator will review the safety inspection form monthly for all homes to ensure compliance. New emergency phone labels were distributed to all homes the week of 7/20/15. |
08/01/2015
| Implemented |
| 6400.164(a) | Individual #1's medication log did not include the time of administration for Ibuprofen 200mg on 3/13/15, 3/16/15, and 4/17/15.
Individual #1's medication log did not include the time of administration for Ventolin HFA on 3/21/15 and 3/29/15.
| 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. | 3/13/15 PRN Ibuprofen was documented as administered at 8pm on a different page of the MAR. 4/17/15 MAR does not reflect that Ibuprofen was administered at all. 3/21/15 Ventolin documented on back of MAR as administered off unit by his family. 3/29/15 Ventolin documented on back of MAR as administered at 10:14pm
The staff who administered the PRN medications will receive re-training (tutoring) by a med admin trainer on proper documentation of a PRN medication. Also, the Med Admin Policy will be reviewed with these associates. This home now uses an electronic MAR so the time of administration will be automatically recorded.
All staff that administer medications will receive training on the importance of documenting the time of the administration of medications, starting within 30 days of receipt of this plan of correction. [SW 0.11.15] |
08/31/2015
| Implemented |
| 6400.164(b) | Individual #1 is prescribed Pataday solution 2%. The medication log did not include initials of the person administering the medication on 3/14/15. Individual #1 is prescribed Gabapentin 300mg. The medication log did not include initials of the person administering the medication on 2/20/15.
| The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. | The staff who administered the medications will be re-trained (tutored) by a med admin trainer on proper documentation of a medication. Also, the Med Admin Policy will be reviewed with these associates. This home now uses an electronic MAR so the initials of the staff who administer the medications will be automatically recorded. The Program Coordinator or designee will conduct an audit of the MAR's on a monthly basis to ensure that required signatures are included on the MAR as required, starting within 30 days of receipt of this plan of correction. [SW 9.11.15] |
08/31/2015
| Implemented |
| 6400.181(e)(13)(viii) | Individual #1's assessment did not include current level and progress over the past year in managing personal property. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | KMc assessment was revised on 7/17/15 to include information on his ability to manage his own personal property. The BARC Developmental Services assessment form was revised on 7/20/2015 to include this as a separate section for all future assessments that are written. The Program Manager/Coordinator will be responsible for ensuring all future assessments include this information, by conducting periodic reviews of all consumers assessments at least quarterly. |
08/01/2015
| Implemented |
| 6400.186(c)(2) | The Individual Support Plan (ISP) reviews for Individual #1 did not include a review of the 2:1 supervision plan that is required in the home and community. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | All subsequent quarterly reviews for KMc will include information on his level of supervision, specifically describing fading plan for his intensive staffing. The quarterly review form was revised on 7/20/15 to include this as a separate section. The Program Manager/Coordinator will be responsible for ensuring all future quarterly reviews include this information by conducting periodic reviews of the ISP reviews on a quarterly basis. |
08/01/2015
| Implemented |