| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(c) | A written fire drill record shall be kept of the time including designation of AM / PM. The fire drill that was conducted on 12/13/23 at 8:13 did not include the designation of AM or PM. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Fire drill forms will be updated to include ¿AM¿ and ¿PM¿ being pre-printed on the forms, so that the staff completing the form can circle the appropriate designator of the time the drill was performed. All staff completing fire drills will be reminded of the requirements for documentation. |
04/30/2024
| Implemented |
| 6400.143(a) | Individual #1's physical examinations on 9/19/23 and 9/15/22 noted a recommendation to follow up with an audiologist. Individual #1 had an audiologist appointment on 3/29/22 and the form documented that the audiometric testing was not able as the patient could not tolerate headphones. On 3/5/24, Individual #1 had an audiology appointment and the form documented refused headphone for test. There was no record or documentation of the attempts to train Individual #1. | 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. | The importance and requirement of documentation to show attempts to train, educate, and desensitize individuals following refusals of medical treatment/testing were reviewed with all staff and Managers at March house meetings. |
03/27/2024
| Implemented |
| 6400.32(r) | An individual has the right to lock the individual's bedroom door. Individual #2 and Individual #3 did not have locks on their bedroom doors. | An individual has the right to lock the individual's bedroom door. | Numeric keypad locks will be installed on bedroom doors. Individuals and staff will be trained on how the locks function. |
04/30/2024
| Implemented |
| 6400.165(c) | Individual #1 is prescribed Ear drops DRO 6.5 %, administer 5 drops into each ear every morning fill ear canal and insert cotton plug, remove plug after 15-30 minutes. At the time of the inspection, Individual #1 had an unopened/sealed box of the medication, and another bottle that contained approximately ¼ of the medication. The pharmacy label on both the unopened box of the medication and the bottle that contained appropriately ¼ of the medication had a fill date of 12/7/23 and QTY 30. Based on the date that the prescription was filled and the quantity of medication remaining, the medication is not being administered as prescribed. | A prescription medication shall be administered as prescribed. | Agency Nurse contacted PDC pharmacy, where medications are received from, to ask that label quantities indicated what the numeric quantity is referring to (days supply, mL, etc.) PDC pharmacy informed Agency Nurse that this was not possible due to the size of the label. Agency Nurse and pharmacy discussed the reasoning behind the request, and it was determined that the best course of action would be to have all medications that are not able to be measured in some way (in order to demonstrate administration compliance,) be refilled on a monthly basis with the regular cycle, regardless of quantity remaining. This will ensure an adequate supply of all non-measurable medications is always on hand, without having to be reordered and then potentially sitting for an extended of time from the date of dispensing before being used. |
04/30/2024
| Implemented |