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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.106 | The furnace was inspected 2/04/2021, 7/21/2021, 1/13/2022, and 6/16/2022 but there is no documentation it was cleaned by a professional cleaning company | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Maintenance staff will be re-certified to inspect and clean the furnace. The Certification will be kept on file. A form will be developed to document the date the Maintenance staff will clean furnaces and inspect the furnace. The furnace will be re-inspected and re-cleaned by October 1, 2022. |
10/01/2022
| Implemented |
| 6400.113(c) | Individual #1's fire safety training did not include the content of the training. | A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept. | Descriptive content detailing what individuals are instructed on during monthly fire drills was developed and will be distributed to all homes as a resource for staff completing the drill and instructing consumers |
09/05/2022
| Implemented |
| 6400.143(a) | Individual #1 refused psychiatric medication review appointments scheduled for 12/21/2021, 2/19/2022, 2/11/2022, 2/16/2022, 3/21/2022, 3/22/2022, and 5/06/2022 and there is no documentation of continued attempts to train the individual about the need for health care. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Individual referred for behavioral supports to address medical appointment refusals |
09/12/2022
| Implemented |
| 6400.165(c) | Individual #1 is prescribe Tamulosin .4mg capsule. During the inspection conducted 7/28/2022 staff were unable to locate the medication in the home., | A prescription medication shall be administered as prescribed. | Medication was prescribed in the emergency room. PCP did not want to refill the medication, it was not properly discontinued and was removed from the home |
09/12/2022
| Implemented |
| 6400.165(g) | Individual #1 had a psychiatric medication review completed 7/14/2022 and the documentation did not include the reason for prescribing the medication. Individual #1 had a psychiatric medication review completed 7/27/2022 and the documentation does not include the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Med review will be sent to the prescribing physician to correct the missing documentation |
09/08/2022
| Implemented |
| 6400.166(a)(11) | Individual #1's July 2022 medication administration record did not include diagnosis or purpose for the following medications: BD Ultra-Fin 32gx X 6mm mis, Cetirizine 10mg tablet, Clonazepam .5mg tablet, Clotrimazole 1% cream, Divalproex 500mg ER tablet, Escitalopram 20mg tablet, Guanfacine 2mg tablet, Hydroxyzine Pamoate 25mg tablet, Insulin Lisp 100/ml injection, Ketoconazole 2% cream, Lantus Solostar 100u/ml injection, Lisinopril 5mg tablet, Metformin 850mg tablet, Niacin ER 500mg tablet, One Touch UL Strips Test, One Touch Del Plus 30g mis
Sea-omega 1000mg capsule, Simvastatin 40mg tablet, Tamulosin .4 mg capsule, and Ziprasidone 80mg capsule. | 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. | Program Specialists and Directors will review all Medication Administration Records to ensure that all medications prescribed have a diagnosis and reason for medication. Any found missing this information will be remediated by contacting the prescribing physician |
10/01/2022
| Implemented |
| 6400.166(a)(13) | Individual #1's July 2022 medication administration record did not include name and initials of person who administered the following medications on 7/25/2022 at 8:00am: BD Ultra-Fin, 32gx X 6mm mis, Cetirizine10mg tablet, Clotrimazole 1% cream, Escitalopram 20mg tablet, Guanfacine 2mg tablet, Hydroxyzine Pamoate 25mg tablet, Insulin Lisp 100/ml injection, Ketoconazole 2% cream, Lansoprazole 30mg capsule, Lantus Solostar 100u/ml injection, Levothroxin, 25mg tablet, Metformin 850mg tablet, Niacin ER 500mg tablet, One Touch UL test strips, One Touch Del Plus 30g, Sea-omega 1000mg capsule, Topiramate 100mg tablet, Urea 40% cream, Vitamin D-3 2000 unit, Ziprasidone 80mg capsule, and Benzoyl Per 10% wash liquid. Individual #1's July 2022 medication administration record did not include the name and initials of the person who administered BD Ultra-Fin, 32gx X 6mm mis on 7/01/2022 at 12:00pm and 4:00pm, 7/07/2022 at 4:00pm, 7/14/2022 at 4:00pm, 7/18/2022 at 12:00pm, 7/24/2022 at 8:00pm, and 7/26/2022 at 12:00pm. Individual #1's July 2022 medication administration record did not include the name and initials of the person who administered Guanfacine 2mg tablet on 7/17/2022 and 7/26/2022 at 8:00am. Individual #1's July 2022 medication administration record did not include the name and initials of the person who administered Hydroxyzine Pamoate 25mg tablet 7/18/2022 and 7/26/2022 at 12:00pm. Individual #1's July 2022 medication administration record did not include the name and initials of the person who administered Insulin Lisp 100/ml injection 7/01/2022 at 2:00pm, 7/18/2022 at 2:00pm, 7/19/2022 at 2:00pm, 7/24/2022 at 8:00pm, and 7/26/2022 at 2:00pm. Individual #1's July 2022 medication administration record did not include the name and initials of the person who administered Ketoconazole 2% cream on 7/17/2022 at 8:00am. Individual #1's July 2022 medication administration record did not include the name and initials of the person who administered Lantus Solostar 100u/ml injection on 7/17/2022 at 8:00am. Individual #1's July 2022 medication administration record did not include the name and initials of the person who administered Metformin 850mg tablet on 7/01/2022, 7/07/2022, and 7/14/2022 at 4:00pm. Individual #1's July 2022 medication administration record did not include the name and initials of the person who administered One Touch UL test strips on 7/01/2022 at 11:00am, 2:00pm, and 5:00pm, 7/07/2022 at 5:00pm, 7/14/2022 at 5:00pm, 7/18/2022 at 11:00am and 2:00pm, 7/24/2022 at 9:00pm, and 7/26/2022 at 11:00am and 2:00pm. Individual #1's July 2022 medication administration record did not include the name and initials of the person who administered One Touch Del Plus 30g mis on 7/01/2022 at 12:00p and 4:00pm, 7/07/2022 at 4:00pm, 7/14/2022 at 4:00pm, 7/18/2022 at 12:00pm, 7/24/2022 at 8:00pm, and 7/26/2022 at 12:00pm. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | Staff will be retrained on documentation of refusals, omission of medication and reporting medication errors |
09/12/2022
| Implemented |
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