| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | · Contact paper under sink needs to be replaced.
· Paint chipping in living room needs to be repainted | Floors, walls, ceilings and other surfaces shall be in good repair. | Request was sent to OPS for areas of non compliance. Contact paper was replaced underneath kitchen sink and area where paint was chipping was repaired and repainted. (Attachment # 38 ) |
12/07/2022
| Implemented |
| 6400.165(b) | Medication Debrox 6.5% ear drops-instill 4 drops in left ear 2x's a day(8am/8pm). 8am signed out on mar as administered on date of inspection, medication not in medication box or in the home for 8pm dosage. Staff was not able to explain or provide when the new prescription would be available. Requested, but not provided. | A prescription order shall be kept current. | Agency nurse contacted current ENT on 11/29/22. He stated he did not prescribe the medication for Individual #1. The previous PCP had prescribed the medication and he would not refill it due to he did not feel she needed it. This medication was signed for in error. Please see current medications she is on and Debrox is removed. (Attachment #40) |
12/02/2022
| Implemented |
| 6400.165(d) | Medication Clobetasol 0.05% cream apply to affected vaginal/groin area 2x's a day (8am & 8pm) for 1 month, then at bedtime (8pm) for 2 months, then twice weekly (Tuesday & Friday at 8pm)-when did it start/end? Only signed out as administered on mar 11/1, and 11/4-requested/not provided. | A prescription medication shall be used only by the individual for whom the prescription was prescribed. | This area of non-compliance was immediately brought to the attention of Agency Nurse who contacted the GYN for clarification. The order on the MAR was when the medication was initially prescribed in April 2021 and was ongoing. At an appointment on 11/15/2022, the order was changed to BID for 10 days only. When the medication was delivered, the staff did not correctly transcribe it on the MAR, as taught in Medication Administration Training. The old order should have been discontinued. Medication has subsequently been discontinued and is no longer on the MAR (Attachment #40) |
12/02/2022
| Implemented |