| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | At the time of this inspection, self-assessments have not been completed. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| 1. The coordinator and the assistant director were offered retraining on the self-inspection tool as it pertains to the 6400 licensing regulations. The retraining occurred on 3/2/2018.
2. The directorship (Director and Assistant Director) of the program will utilize an Outlook Calendar in order to prompt them to begin the self-inspection process within the 3-6 months prior to the expiration date. The directorship will be responsible for assisting the house managers in completing the inspections.
3. Future audits of all homes self-inspection tools will be conducted by a candidate outside of the program that is familiar with the regulations. All concerns found during any audit will be corrected immediately and will be addressed during supervision.
4. Supporting documentation of retraining will be emailed. |
03/02/2018
| Implemented |
| 6400.167(a) | Staff #1 was hired on 7/10/2017 & does not have medication administration training. Staff #2, staff #3 and staff #4 do not have med practicums. All 4 staff have been passing medications. | Prescription medications and injections of a substance not self-administered by individuals shall be administered by one of the following: (1) A licensed physician, licensed dentist, licensed physician's assistant, registered nurse or licensed practical nurse. (2) A graduate of an approved nursing program functioning under the direct supervision of a professional nurse who is present in the home.(3) A student nurse of an approved nursing program functioning under the direct supervision of a member of the nursing school faculty who is present in the home. (4) A staff person who meets the criteria specified in § 6400.168 (relating to medications administration training) for the administration of oral, topical and eye and ear drop prescriptions and insulin injections. | 1. The staff and supervisor was offered retraining on the medication administration requirements as it pertains to the 6400 licensing regulations. The retraining occurred on 3/2/2018.
2. The home's staff were trained on Medication Administration Course 1/3/2018 and 1/9/2018. The practicums will be done yearly and tracked on a programs spreadsheet.
3. The directorship of the program will be responsible for ensuring that all approved trainers teaching medication administration to staff have a current certification.
4. The home¿s supervisor will closely monitor all future medication training of staff to ensure compliance of the 6400 regulations. The home¿s supervisor will be responsible for ensuring that all staff are properly trained on the regulations and understand the need for timely medication certification by an approved trainer.
5. Future audits of all staffs medication training records will be conducted by a candidate outside of the program that is familiar with the regulations. All concerns found during any audit will be corrected immediately and will be addressed during supervision.
6. All supporting documentation of correction will be emailed. |
03/02/2018
| Implemented |
| 6400.168(a) | Staff #1 was hired on 7/10/17. She does not have medication administration training and has been passing medications. | In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. | 1. The coordinator and supervisor was offered retraining on the Medication Administration Course requirements as it pertains to the 6400 licensing regulations. The retraining occurred on 3/2/2018.
2. The coordinator will ensure that all new staff are trained prior to administering medications. The home's staff were trained on 1/3/2018 and 1/9/2018.
3. The home¿s supervisor and directorship will work together to closely monitor all future medication training of staff to ensure compliance of the 6400 regulations. The home¿s supervisor will be responsible for ensuring that all staff are properly trained on the regulations and understand the need for timely medication certification by an approved trainer.
4. Future audits of all staffs medication training records will be conducted by a candidate outside of the program that is familiar with the regulations. All concerns found during any audit will be corrected immediately and will be addressed during supervision.
5. All supporting documentation of correction will be emailed. |
03/02/2018
| Implemented |
| 6400.168(c) | Staff #5 and staff #6's trainer certifications both expired 3/4/2017. Because of this, staff #1's initial training (11/3/17) and Staff #2 & Staff #3's practicums (both 7/1/17) are not valid. | Medications administration training of a staff person shall be conducted by an instructor who has completed the Department's Medications Administration Course for trainers and is certified by the Department to train staff. | 1. The staff and supervisor was offered retraining on the medication administration requirements as it pertains to the 6400 licensing regulations. The retraining occurred on 3/2/2018.
2. The certified trainer who completed the Department¿s Medication Administration Course for Certified Trainers was completed by 12/13/2017. The home's staff were trained on Medication Administration Course on 1/3/2018 and 1/9/2018. Practicums will be completed yearly and tracked on program spreadsheet.
3. The directorship of the program will be responsible for ensuring that all approved trainers teaching medication administration to staff have a current certification.
4. Future audits of all staffs medication training records will be conducted by a candidate outside of the program that is familiar with the regulations. All concerns found during any audit will be corrected immediately and will be addressed during supervision.
5. All supporting documentation of correction will be emailed. |
03/02/2018
| Implemented |
| 6400.168(d) | Staff #4 does not have a Med Practicum and has been administering medications. | A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. | 1. The staff and supervisor was offered retraining on the Medication Administration Course requirements as it pertains to the 6400 licensing regulations. The retraining occurred on 3/2/2018.
2. The home's staff were trained in the Medication Administration Course on 1/3/2018 and 1/9/2018. Practicums will be done yearly and tracked on a program spreadsheet.
3. The home¿s supervisor and directorship will work together to closely monitor all future medication practicums of staff are in compliance of the 6400 regulations. The home¿s supervisor will be responsible for ensuring that all staff are properly trained on the regulations and have completed and passed the medication administration course practicum yearly.
4. Future audits of all staffs medication training records will be conducted by a candidate outside of the program that is familiar with the regulations. All concerns found during any audit will be corrected immediately and will be addressed during supervision.
5. All supporting documentation of correction will be emailed. |
03/02/2018
| Implemented |
| 6400.168(e) | Documentation of initial med training for staff #7 was not kept. Documentation of med practicums for staff #4 was not kept. | Documentation of the dates and locations of medications administration training for trainers and staff persons and the annual practicum for staff persons shall be kept. | 1. The staff and supervisor was offered retraining on the Medication Administration Course requirements as it pertains to the 6400 licensing regulations. The retraining occurred on 3/2/2018
2. All documentation of the dates and locations of medications administration training for trainers and staff, along with copies of the annual practicum, will be kept in a master file at the office along with the home.
3. The home¿s supervisor and directorship will work together to closely monitor all future medication trainings and practicums of staff are in compliance of the 6400 regulations. The home¿s supervisor will be responsible for ensuring that all staff are properly trained on the regulations and have completed the training and passed the medication administration course practicum yearly.
4. Future audits of all staffs medication training records will be conducted by a candidate outside of the program that is familiar with the regulations. All concerns found during any audit will be corrected immediately and will be addressed during supervision.
5. All supporting documentation of correction will be emailed. |
03/02/2018
| Implemented |