|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.135(g) | Individual #1, date of admission 1/01/2022, is prescribed a medication to treat symptoms of a diagnosed psychiatric illness. A medication review was completed by a licensed physician on 3/01/2022 and then again on 8/16/2022. This exceeds the 3-month requirement. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review by a licensed physician at least every 3 months to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Psychiatric medication management will be completed at least every 3 months to document the reason for prescribing the medication, the need for continuing the medication and the necessary dosage. The treating doctor will be responsible for this change. The change has been made immediately. The Health Care Provider has also been provided a copy of our regulations.
Regularly scheduled appointments have been setup on a recurring basis, and the Assigned Program Specialist will monitor the appointment dates for timeliness.
We have ensured the Prescribing Doctor has a copy of the regulations, and the Program Specialist will review continuity of care appointment forms. The Assigned Program Specialist will maintain a spreadsheet of appointment dates coinciding with the appropriate regulations.
Training / Retraining will be provided to the Program Specialist and Provider on 6500.135(g), which is If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review by a licensed physician at least every 3 months to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. [Documentation of completed psychiatric medication review for individual, dated 12/8/22, was received on 2/15/23 and reviewed 2/27/23. Documentation of training related to regulation 6500.135g, dated 1/13/23, was received on 2/15/23 and reviewed 2/27/23. DPOC by HDKP, HSLS, on 2/27/23.] |
12/27/2022
| Implemented |
| 6500.136(a)(11) | Individual #1's November 2022 Medication Administration Record did not include the diagnosis or purpose for the following medications: Aspirin 325 MG - Take one tablet by mouth daily; Vitamin D3 25 MCG - Take one softgel by mouth once daily; Citalopram Hydrobromide 40 MG Tab Auro - Take one tablet by mouth every day; Bupropion Hydrochloride Er (Sr) 12 hr 100 MG Tab - Take one tablet by mouth everyday; and Quetiapine Fumarate 50 MG Asce - Take one tablet by mouth every day. | 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. | The individual will utilize the L'Arche Erie Pharmacy of choice who will make the change in provider. Once the individual has been setup with our pharmacy, the medication administration record will be created to include diagnosis and purpose for medications. The Physician / Nursing Department will be responsible for this change.
Individual and Provider have been notified the change in pharmacy must be completed within 30 calendar days.
Nursing Department will work with contracted pharmacy to get individual #1 enrolled. Once enrolled, Nursing Department will provide correct MAR forms to Provider, which will include individual #1's diagnosis and purpose for medications.
Individual #1 will be enrolled in contracted pharmacy, MARs will be checked by Nursing Department before sent to Provider to ensure they include diagnosis and purpose for each medication, and training will be provided to the Provider.
Provider will be retrained by January 10, 2023, on 6500.136(a), which is that a medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for medication, include pro re nata. [Documentation of a blank individual Medication Administration Record (MAR), that does not indicate the month or year, but contains a diagnosis or purpose for each prescribed medication was received on 2/15/23 and reviewed 2/27/23. Documentation of training for Life Sharing provider related to regulation 6500.136, dated 2/9/23, was received on 2/15/23 and reviewed 2/27/23. DPOC by HDKP, HSLS, on 2/27/23.] |
01/10/2023
| Implemented |
| 6500.136(b) | On 11/23/22, the following medications for Individual #1 were recorded as administered through and including 11/30/2022: Aspirin 325 MG - Take one tablet by mouth daily; Vitamin D3 25 MCG - Take one softgel by mouth once daily; Citalopram Hydrobromide 40 MG Tab Auro - Take one tablet by mouth every day; Bupropion Hydrochloride Er (Sr) 12 hr 100 MG Tab - Take one tablet by mouth everyday; and Quetiapine Fumarate 50 MG Asce - Take one tablet by mouth every day. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The Provider will not sign medication records in advance, but instead, sign the record at the time the medication is administered. The LS provider will be responsible for this change.
The change will happen Immediately; Provider was informed on 11/23/2022 that all medication recordings on and after that date should be at the time the medication is administered.
Provider has stopped pre-dating medication records.
The Program Specialist and / or Medication Administration Certified Trainer will complete random checks in the home to verify medication records are not being signed off prior to the medication being administered.
The Provider will be retrained on 6500.136(a-d) by January 10, 2023, and the Provider will be required to sign and date the retraining form. The form will be maintained by HR. [Documentation of a blank individual Medication Administration Record (MAR), that does not indicate the month or year, but contains a diagnosis or purpose for each prescribed medication was received on 2/15/23 and reviewed 2/27/23. Documentation of training for Life Sharing provider related to regulation 6500.136, dated 2/9/23, was received on 2/15/23 and reviewed 2/27/23. Documentation of "random check" of medication administration documentation, dated 2/9/23, was received on 2/15/23 and reviewed 2/27/23. DPOC by HDKP, HSLS, on 2/27/23.] |
01/10/2023
| Implemented |
| 6500.139(a) | Life Sharing Caregiver #1, date of hire 1/01/2022, completed the modified medication administration course on 2/28/2020. On 11/23/22, the recertification course has not yet been completed by Life Sharing Caregiver #1. This exceeds the 2-year requirement. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6500.132 (relating to medication administration). | Provider will be enrolled in Medication Administration Training course by December 31, 2022.
Certified Medication Administration Trainer and LS Provider will be responsible for the change.
Provider will be enrolled in Medication Administration Training course by December 31, 2022. Course will be completed no later than January 31, 2023.
Certified Medication Administration Trainer is required to enroll provider in the Medication Adminstration Training Course by December 31, 2022. Once the Provider has been enrolled, the Provider is required to fulfill online and face-to-face training requirements. Certified Medication Administration Trainer will track training completion date once the Provider is considered re-certified to ensure re-training is completed within 730 days (2 years) from the last course completion date.
Certified Medication Administration Trainer will track training completion date once the Provider is considered re-certified to ensure re-training is completed within 730 days (2 years) from the last course completion date. All Medication Administration Training records are record due dates are maintained within BambooHR for Providers and employees. This system provides reminders of upcoming due dates to Providers and the Certified Medication Administration Trainer.
The Certified Medication Administration Trainer has been provided training / retraining on 6500.139. The retraining record will be kept in the employee's file. Also, the Provider will review 6500.139, and complete an in-service training by December 31, 2022. [Documentation of training in relation to regulation 6500.139 for the Medication Administration Trainer, dated 12/27/22, was received on 2/15/23 and reviewed 2/27/23. Documentation of training in relation to "Medication Administration in Lifesharing Homes," dated 1/13/22, was received on 2/15/23 and reviewed 2/27/23. Documentation of training for Life Sharing Provider related to regulations 6500.136 and 6500.139, dated 2/9/23, was received on 2/15/23 and reviewed on 2/27/23. Documentation that Life Sharing Provider completed the Modified Medication Administration Course Renewal, dated 2/14/23, was received on 2/15/23 and reviewed 2/17/23. DPOC by HDKP, HSLS, on 2/27/23.] |
01/31/2023
| Implemented |
|
|