| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.163(d) | The controlled medications in the home were not double-locked. The provider sent documentation showing that this was fixed on the same day, following the site inspection. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | Program director sent email to OPS, requesting a lock placed on cabinet in storage area Attachment # 45. Individual¿s medication was immediately double locked as required Attachments # 46. All med certified staff received a memo, reminding them of the proper storage of medication and the need for controlled substances to be double locked Attachment # 47. To prevent future occurrence: Medication checklist was updated to include controlled substance being double locked Attachment # 48. All med certified staff received a memo, reminding them of the proper storage of medication and the need for controlled substances to be double locked Attachment # 47. |
11/29/2021
| Implemented |
| 6400.163(h) | The following medications for Individual 1 were not current or active medications, but were still in the individual's medication box:
1. Claritin 10MG - Take one tablet by mouth every day.
2. Atarax 25MG - Take one tablet by mouth at bedtime as needed for itching.
3. Ativan 0.5MG - Take 1 tablet by mouth 15-20 minutes prior to MRI .
4. Olopatadine SOL 0.1% eyedrops - 1 eye drop in both eyes 2 times a day. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Non active medications were immediately removed from medication box and returned to the agency nurse for proper disposal. Agency nurse contacted individual¿s current PCP on 12/2/2021 to get clarification of prescribed medication. Previous PCP had prescribed the medication. Current PCP discontinued Claritin, Atarax, and Ativan. Eyedrops updated to 8 hours PRN Attachment # 49. All med certified staff received reminder memo on how to properly discontinue and dispose of non-active medication Attachment # 50. To prevent future occurrences: All med certified staff received reminder memo on how to properly discontinue and dispose of non-active medication Attachment # 50. |
12/02/2021
| Implemented |
| 6400.165(e) | The following medications for Individual 1 were documented on the Medication Administration Record (MAR), but were not present in the individual's medication box:
1. Colace 100MG - Take one tablet by mouth 2 times a day as needed for constipation.
2. Motrin 600MG - Take one tablet by mouth 2 times a day as needed for pain.
3. Senna 8.6MG - Take one tablet by mouth 2 times a day as needed for constipation.
4. Ventolin HFA 90 MCG Inhaler - Inhale 2 puffs by mouth every 6 hours as needed.
5. Artificial Tears - Install 2 drops in both eyes every 8 hours as needed. | Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received. | Agency nurse contacted individual¿s current PCP on 12/2/2021 to get clarification of prescribed medication. Previous PCP had prescribed the medication. Current PCP refilled Colace, Motrin, Senna, and Artificial tears PRN Attachment # 52. MAR updated as needed Attachment # 53. To prevent future occurrences: Medication checklist used to document that medication in box match MAR Attachment # 54. |
12/02/2021
| Implemented |
| 6400.166(b) | On the medication record for Individual 1, there were no initials or other documentation on 11/27/2021 for the following medication: Mysoline 50MG Tablet - Take 4 tablets by mouth at bed time. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Staff who passed medication initialed Mysoline 50mg tabs bedtime 11/27/2021 Attachment # 55. Staff responsible for documentation error received memo, reminding him of properly documenting all medication administrations Attachment # 56.
To prevent future occurrences: Medication checklist Attachment # 57 is used to document that MAR is signed and accurate. |
01/10/2022
| Implemented |