Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.144 | Individual #1's 6/7/24 Individual Support Plan indicates they are to be using a hand splint on their left hand; however, this has not been in use in the home. There was not a discontinue order on file from a medical provider for ceasing the use of this splint until 11/5/24.
Individual #1 is incontinent and requires staff assistance to reposition to prevent skin breakdown. This is to be done every 2 hours. There is tracking to be completed, however, it is completed per shift as opposed to every 2 hours and is frequently not completed by staff. | 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.
| Discharge order for hand splint was obtained on 11/5/24. Team member who failed to obtain written instructions prior to 11/5/24 is no longer employed at Friendship Community.
A system has been implemented where Residential Managers are now confirming in an electronic system that they have checked documentation for completion on a weekly basis. |
01/31/2025
| Accepted |
6400.18(b)(2) | A medication error occurred on 8/25/24, was discovered on 9/12/24, and was not entered into the department's incident management system until 9/18/24. | 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 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | The Nursing team, including the nurse who discovered the error during a MAR Review but did not report it sufficiently which led to the late EIM report, was instructed to notify both the Residential Manager and Coordinator as soon as they discover a med error, since a Neglect report might need to be entered in addition to the Medication Error report. |
01/01/2025
| Accepted |
6400.52(c)(6) | Individual #1 has an Individual Support Plan (ISP), aspiration risk which requires Fatal Five training, and a hoyer lift for transfers that staff need to be trained in before working with Individual #1. Staff persons #10, 16, 17, 18, and 20 were not trained in Individual #1's ISP before working with Individual #1. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | Train staff persons #10, 16, 17 on Individual #1's most recent ISP and trainings required to work with Individual #1. Complete trainings with staff persons #18 and 20 if they return to Individual #1's home to complete cross-training process. |
12/31/2024
| Accepted |
6400.166(a)(2) | Individual #1's September 2024 Medication Administration Records do not include the prescriber for Doxycycline. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | Train eMAR Facilitators to check to ensure that all required details are present when verifying medication orders in the eMAR. |
01/01/2025
| Accepted |
6400.166(a)(5) | Individual #1's September 2024 Medication Administration Records do not include the strength for Doxycycline. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | Train eMAR Facilitators to check to ensure that all required details are present when verifying medication orders in the eMAR. |
01/01/2025
| Accepted |
6400.166(a)(11) | Individual #1's September 2024 Medication Administration Records do not include the diagnosis or purpose for Vitamin D2 and Doxycycline. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Train eMAR Facilitators to check to ensure that all required details are present when verifying medication orders in the eMAR. |
01/01/2025
| Accepted |
6400.166(a)(14) | Individual #1's September 2024 Medication Administration Records do not include the duration of treatment for Doxycycline. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Duration of treatment, if applicable. | Train eMAR Facilitators to check to ensure that all required details are present when verifying medication orders in the eMAR. |
01/01/2025
| Accepted |