| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Dial Complete antibacterial hand soap was found unlocked in both bathrooms. | Poisonous materials shall be kept locked or made inaccessible to individuals. | The Dial Complete antibacterial soap was removed from both bathrooms and locked .The Agency has revised and added additional details to Physical Site Monthly Inspection checklist.
Agency provided additional training to all House Supervisors, Program Directors and Residential
Directors in using the new tool and reviewed all Citations from this licensing visit.
Beth Davidson will email ODP October completed checklist on revised form completed by the House Supervisor and also Training documentation. |
10/11/2017
| Implemented |
| 6400.151(c)(2) | Staff person #1's physical examination dated 1/16/17 did not document the results of the tuberculin test administered on 1/16/17. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | Staff person #1 physical form was returned to her PCP and he documented her negative Mantoux results.
Beth Davidson reviewed with all HR staff the need for all sections of employee physical form to be completed . Beth Davidson will email ODP physicals forms completed since licensing visit and corrected form for Staff #1. |
10/11/2017
| Implemented |
| 6400.167(b) | Individual #1's PRN medications Ibuprofen and Tylenol were being administered together daily for pain. Which the physicians order did not reflect how the medications were being administered. | Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Staff contacted Individual #1's PCP and he changed the Tylenol PRN medication to 2 times daily instead of PRN. Ibuprofen orders remained the same: take 1 tablet by mouth 3 times daily as needed for menstrual cramps.
Jenn Fox Medication Trainer reviewed and retrained Program Supervisor in medication Administration procedures re: PRN medications.
Beth Davidson will email BHSL copies of training documentation and Individual #1's MAR to demonstrate compliance. |
10/11/2017
| Implemented |