Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.144 | Institute for Human Resources and Services failed to provide health services to Individual #1. The prescription Loxapine was not administered on the following dates due to the medication not being refilled: at 8pm on 2/12/2020 and at 8AM on 2/13/2020. The prescription Polyethylene Glycol (17gm BID) was not administered on the following dates due to the medication not being refilled: at 8AM on 1/11/2020 and 1/12/2020, at 8PM on 1/10/2020 and 1/11/2020, at 8AM 2/3-2/6/2020, and at 8PM 2/2-2/6/2020. The prescription for Propanolol (80mg TID) was not administered on the following dates due to the medication not being refilled: 2/9/2020 at 2PM, 2/9/2020 at 8PM and 2/10/2020 at 8AM. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| All medication errors reported during the unannounced visit will be verified and filed in the EIM system. Medication error follow-up will be provided with each employee as per the agency's medication error policy. PCP was contacted and agency is attempting to get documentation on directive for medication errors.
IHRS will review with employees that at least a 10 day supply of medications should be on site at all times. Efforts to obtain medications running low will begin early to avoid missed medications and medication errors. IHRS has discussed with agency pharmacy ways to remedy issues moving forward. |
04/30/2020
| Implemented |
6400.18(b)(2) | Medication Errors are incidents required to be reported in EIM within 72 hours. The following medication errors occurred for Individual #1: Polyethylene Glycol (17gm) at 8AM on 1/11/2020 and 1/12/2020, at 8PM on 1/10/2020 and 1/11/2020, at 8AM 2/3-2/6/2020, and at 8PM 2/2-2/6/2020; Propranolol HCL (80mg) at 2PM and 8PM on 2/9/2020, and at 8AM on 2/10/2020; Loxapine (100mg) at 8pm on 2/12/2020, Loxapine (50mg) at 8AM on 2/13/2020. These medication errors were not reported in EIM. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | All medication errors reported during the unannounced visit will be verified and filed in the EIM system. Medication error follow-up will be provided with each employee as per the agency's medication error policy. PCP was contacted and agency is attempting to get documentation on directive for medication errors. |
04/30/2020
| Implemented |
6400.32(c) | Individual #1's health needs were neglected on 2/9/2020 and 2/10/2020. The prescription for Propanolol (80mg TID) ran out and the following doses were not administered: 2/9/2020 at 2PM, 2/9/2020 at 8PM and 2/10/2020 at 8AM. On the morning of 2/11/2020, her blood pressure was high (160/106). She was taken to the Emergency Room where she had to be treated with IV medication to get her blood pressure back to normal. Individual #1's health needs were neglected as the provider agency failed to obtain blood pressure medication once the prescription has run out. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | IHRS will review with employees that at least a 10 day supply of medications should be on site at all times. Efforts to obtain medications running low will begin early to avoid missed medications and medication errors. IHRS has discussed with agency pharmacy ways to remedy issues moving forward. |
04/10/2020
| Implemented |
6400.165(c) | The following medications were not administered to Individual #1 as prescribed: Polyethylene Glycol (17gm) at 8AM on 1/11/2020 and 1/12/2020, at 8PM on 1/10/2020 and 1/11/2020, at 8AM 2/2-2/6/2020, and at 8PM 2/2-2/6/2020; Propranolol HCL (80mg) at 2PM and 8PM on 2/9/2020, and at 8AM on 2/10/2020; Loxapine (100mg) at 8pm on 2/12/2020, Loxapine (50mg) at 8AM on 2/12/2020 and 2/13/2020. | A prescription medication shall be administered as prescribed. | IHRS will review with employees that at least a 10 day supply of medications should be on site at all times. Efforts to obtain medications running low will begin early to avoid missed medications and medication errors. IHRS has discussed with agency pharmacy ways to remedy issues moving forward. |
04/10/2020
| Implemented |
6400.166(b) | The following medications were not initialed as administered to Individual #1: Polyethylene Glycol (17gm) and Ocusoft Foaming Lid Scrub at 8AM on 2/21/2020. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | IHRS will review missing information with employee who passed 8am medications on 2/21/20. Employee will be issued training and disciplinary action under IHRS's Medication Documentation Policy. |
04/30/2020
| Implemented |
6400.167(b) | The following medication errors occurred for Individual #1: Polyethylene Glycol (17gm) at 8AM on 1/11/2020 and 1/12/2020, at 8PM on 1/10/2020 and 1/11/2020, at 8AM 2/3-2/6/2020, and at 8PM 2/2-2/6/2020; Propranolol HCL (80mg) at 2PM and 8PM on 2/9/2020, and at 8AM on 2/10/2020; Loxapine (100mg) at 8pm on 2/12/2020, Loxapine (50mg) at 8AM on 2/13/2020. There is no documentation of these medication errors or follow-up action taken by the agency. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | All medication errors reported during the unannounced visit will be verified and filed in the EIM system. Medication error follow-up will be provided with each employee as per the agency's medication error policy. PCP was contacted and agency is attempting to get documentation on directive for medication errors. |
04/30/2020
| Implemented |