| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Individual #1's record does not include an inventory of their property record/personal possessions deposited by the family. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | It is important to account for all of the indiviudal possessions so that there is no chance of loss or theft. When Indiviudal # 1 moved in her family were clearing out a house which Ind lived in and writing an inventory as they brought property into the home. The home has a new house supervisor that has been educated on the licensing requirements. the Supervisor and indiviudal completed her personal inventory. The Supervisors responsibility around maintaining that inventory was reviewed so that accurate inventory sheets are maintained. They have been educated on their responsibility - see supervisor training. Attachment: CCR # 20 Inventory |
11/26/2019
| Not Implemented |
| 6400.22(d)(2) | Individual #1 was not assessed to be able to handle any amounts of money independently. The individual has a food stamp credit card that she has been carrying and there isn't a financial ledger to monitor the money on this card.
The individual's 11/5/19 petty cash receipt entry stated there was a receipt for the $20 spent at the logan valley mall. The receipt was not in the financial record for the individual. There were additional receipts in the individual's financial record that were not logged on the individual's daily financial ledger. The receipts were $9.43 at Charley's Philly Steaks on 11/6/19, $10.49 generic receipt on 11/13/19, and $1.48 for Martin's store on 11/2/19.
Individual's 10/30/19 financial record listed that $10 was deducted for bowling. This $10 was actually disbursed to the individual and it was not recorded as such. The form to document the individual received the money, was blank. | (2) Disbursements made to or for the individual.
| In order to prevent an individual from being taken advantage of it is important that money is handled as the indiviudals ISP. The ISP states that the parents and guardians recommend that the individual can only safety handle $ 20. The individual is in possession of her food stamp card. We do not have a financial ledger for this card and there fore cannot tell if she has exceeded the recommeded money managmenet ... Attachment: CCR # 21 Individual Finance Policy Attachment: CCR # 17 Sample Ledger Attachment: CCR # 18 Food Stamp Ledger Sample Attachment CCR - 19 Policy and training Assuring accurate petty cash reciepts will prevent loss of funds and assure the individal is not taken advantage of. The individual has a history of being very independent and haveing others maintain control of her mone is a stressor for her. It is imporatant that we assess current level of support, and assure that her money is accounted for. The House Supervisors are also responsible for assuring the petty cash vouchers and food stamp ledger are accurate each month. She has train the Supervisor fro the immediate need with additional training to come. Attachment: CCR # 21 Individual Finance Policy Attachment: CCR # 17 Sample Ledger Attachment: CCR # 18 Food Stamp Ledger Sample Attachment CCR - 19 Policy and training the House Supervisor is responsible for maintaining a compresensive cash ledger . The staff report that they are rushing when they need to access the petty cash. The were not aware they were to log any change that Individual # 1 keeps following a purchase. The petty cash ledger contained a ledger with a withdrawal notation but not other indication where it was disperced to. Attachment CCR - 16 |
11/26/2019
| Not Implemented |
| 6400.76(a) | There was approximately a golf-ball sized piece of lint left in the dryer. The washer and dryer were not currently being utilized. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The House Supervisor is responsible for the safety of equipment in the home. The cleaning of the lint trap should occur with each load of laundry. All House Supervisors were educated on the need to assure that they monitor all dryers. All homes were provided signs to post on al dryers advising staff to clean the lint trap. All staff were trained. Attachment: # 16 Supervisor Training |
11/26/2019
| Not Implemented |
| 6400.104 | The current 6/13/19 fire notification letter sent to the fire department did not include individual #1's current ability to evacuate the home in the event of a fire or emergency. The letter stated that she could safely evacuate the home. According to the individual's 7/31/19 assessment, she needs assistance to evacuate the home and may not hear the alarm during the over night drills. She's refused 3 fire drills since her date of admission | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Ability to evacuate during a drill is a safety issue which must be clearly understood. Upon admission the individal was listed as able to evacuate without assistance. In the following months the direct care staff noted on fire drills problems with the indivual evacuating. These concerns were not discussed with the Program Specialist and they were not provided copies of the fire drills showing the deteriorating abilities. In order to assure onging assessment of safety skills the fire drills they will be posted on a secure central server and will be reviewed monthly. The program specialist will be responsible for updating the assessment when changes in functioning abilities are noted. The House Supervisor is responsible to schedule the fire drills and monitor responses on the form. First responsible for assuring that any obsticles discovered during a fire drill to the appropriate department to solve the concern. The Program Specialist will notify the Chief Executive Officer or designee of a change in assessed need that requires an updated letter to the fire department. ATTACHMENT: CCR # 15 Letter to the fire company floor plan. The team will continue to address safety needs while determining any cause for the failure to respond to the alarm. The Assessment has been updated to include the new information CCR: # 2 Assessment Ind #1 |
11/26/2019
| Not Implemented |
| 6400.113(a) | Individual #1's date of admission was 6/14/19 and she did not have fire safety training until 6/18/19. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Prompt completion of the fire safey training is critical in assuring that we understand the level of support needed for the person and we are able to support that with their current level of need. Upon admission all Supervisors are ti schedule an immediate fire drill to occure the first day of admission to begin the assessment of need. The Supervisor did not complete her task. All supervisors have had training to refersh the fire safety regulations and their importance. This team did not include the program specialist or medical coordinator as part of the process and the Supervisor failed to complete the fire safety training when admitted. We have created an Admission Team with representatives of from each department. All admisions will include representatives from all departments so that information is complete at time of admission CCR - 12 Admission Team Policy |
11/26/2019
| Not Implemented |
| 6400.141(c)(13) | Individual #1's 4/1/19 physical examination did not include any allergies. According to the individuals individual support plan (ISP), the individual has an allergy to bee stings. The individual's psychiatric medication reviews on 11/7/19 and 7/18/19 list bee sting as an allergy for the individual. (individual's mother called to say it wasn't a true allergy just that the individual gets excited with bee stings and jittery and the medication, Benadryl, helps calm her down) | The physical examination shall include: Allergies or contraindicated medications. | We must assure an accurate physical to assure health and safety for the individual. This physical was part of a new admission and was accepted without review by medical coordinator. The reports include partial information that ind 1 is allergic to bee stings. Information from the individal and family is that she is not allergic to bee stings but gets "excited". Consultation with the individuals pcp and other phsycians shows inconsistencies that cannot be corrected without further testing. The medical coordinator has scheduled testing with an alergist to determine the level of need which is scheduled for January 10. 2019 as first available date for a full review. The information provided to the team at the time of admission did not meet regulatory requirements. Moving forward all admissions will be overseen by a team of members including Medical Coordinator, Nursing services and program specialists. All admissions will include a medical coordiantor or nursing team member to establish a clear and consistent hisitory. |
11/27/2019
| Not Implemented |
| 6400.141(c)(15) | Individual #1's dietary information was not included on their 4/1/19 physical examination. Dietary information from the individual's primary care physician wasn't obtained until the 11/14/19 onsite inspection. | The physical examination shall include: Special instructions for the individual's diet. | We must maintain accurate dietary information in or to assure health and safety. This was a new admision and the physical was completed by another agency. Under dietary info the form said :see attached but none of the attachments contained dietary information. We requested from the Support Coordinator any attachments regarding dietary section and recieved docuentation related to the April physical date. Medical Coordinator reviewed the document obtained on 11/14 with admission dietary information ... Medical Support staff gathered additional information in addition to the infomation on the ISP to develop a dietary plan for Indivual # 1. Moving forward all intake teams will consist of representatives from All departments including medical in order to prevent incomplete information. Attachment: Admission Policy CCR-12 |
11/27/2019
| Not Implemented |
| 6400.144 | On Individual #1's most recent physical dated 4/01/19, constipation was notated by a staff member on 9/9/19 but wasn't faxed to the agency medical coordinator until 10/10/19 for which a miralax script was sent to the pharmacy. | 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.
| The Issues of Concern document is a process by which the direct Support staff can notify medical support of issues they are concerned about. The Medical Coordinator upon reciept of the document noticed that the date written by the DCP was 9/9 but she recieved in on 10/10 (faxed the night before from the home to the medical office). The Medical Coordinator noted the discrepancy by circling the electronic fax date showing she recieved it on 10/10 and she dated it 10/10 but she failed to note that she followed up with staff to discover if it was a date error by staff. In order to improve accuracy the form was revised to allow for staff to enter date and time . Medical Coordinators were educated on the need to document any inconsistencies on forms that have inconsistent information. Attachment : CCR #14 Notice of Concern (revised) The information provided at admission was outdated and updated information has been established. The individuals annual exam is scheduled for January 10th 2019 at the first available date for a full review. |
11/27/2019
| Not Implemented |
| 6400.181(e)(4) | Individual #1's 7/31/19 assessment did not include her supervision needs in the community. The assessment only addressed supervision needs in the home. | The assessment must include the following information: The individual's need for supervision.
| The current assessment was completed in the new ECP online system and upon review it is determined that the Supervision section does not prompt the program specialist to respond to the Community supervision level, supervision level with transportation and supervision level with day program. Until we can determine the source of the formatting changes the program specialist with use the original word document. The assessment has been updated to include the missing information and shared with the team. The Program Specialist will review all other ECP formatted assessments to assure the missing information is present. Attachment CCR # 12 Admission Team ; Attachment CCR # 13 Admission educaton |
11/27/2019
| Not Implemented |
| 6400.181(e)(9) | Individual #1's 7/31/19 assessment did not include their recommended dietary information. The assessment stated "she follows a healthy diet low in fat/salt as well as sugar, she watches her portion sizes and number of servings." However the 5/30/19 dietary information from her primary care physician stated she should, "follow a low fat and low carbohydrate diet. This includes limiting soda intake to up to 12 ounces a day; may drink water otherwise. Also please encourage her to eat primarily fresh foods (fruits, vegetables, healthy proteins) and avoid snacking before or after mealtimes. Due to her recent weight gain, it is also recommended that she does not eat more than single portions at scheduled mealtime." The individual had a neuropsychological evaluation completed in December 2018 which indicated diagnosis of neurocognitive disorder due to multiple etiologies. The report also read "possible neurodegenerative dementia. This is not included in her assessment. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | An accurate and living assessment is crutial to understanding the changing support needs of the individual. To assure that it is maintained and updated by the program specialist will assure appropriate supports. At the time of admission Individual #1 initial assessment completed on 7/31/19 failed to included a lifetime medical history. Medical Coordiantor stated that she failed to realize that the LMH needed included in the indiviuda assessment which was due 60 days after admssion. She completed the Lifetime Medical History one month after the completion of the assessment. The Medical Coordinator has been educated to understand the admission process and components of the indiviudal assessment. Indivudal #1 Assessment has been revised to include the full diagnosis and history, reviewed with the individual and shared with the team. All files have been reviewed to assure the presance of the most recent dietary recommendatons. The Program Specialist did not review the information from the primary care physician with regard to the dietary needs. Medical Coordinators take some time to develop a clear set of physician orders which are updated with the annual physicial unless otherwise noted. The Program Specialist have been educated to understand the need to communicate during the devleeoplment of the assessment in order to review the most accurate information available. The Program Specialist has reviewed and revised the individuals July assessment and shared with the team. (Attachment : CCR # 1 Assessment Cover Letter; Attachment: CCR # 2 Individual #1 Assessment; |
11/27/2019
| Not Implemented |
| 6400.181(e)(10) | Individual #1's 7/31/19 assessment did not include her lifetime medical history. The assessment stated that the lifetime medical history is a separate document that was updated on 8/6/19, after the assessment was created and sent to team members. | The assessment must include the following information: A lifetime medical history. | The Lifetime Medical History is a vital component of the individual assessment because the of health and safey impact has on the person support needs. At the time of admission Individual #1 initial assessment completed on 7/31/19 failed to included a lifetime medical history. Medical Coordiantor stated that she failed to realize that the LMH needed included in the indiviuda assessment which was due 60 days after admssion. She completed the Lifetime Medical History after the completion of the assessment on 8/6/19. The Medical Coordinator has been educated to understand the admission process and components of the indiviudal assessment. A new process has been developed where the Lifetime Medical History is now available on a shared access location on the central server and both the Medical Coordinator and Program Specialist are responsible for updating the record as necessary. The Program Specialist will include the Lifetime Medical History in the assessment rather than as attachment to avoid the two documents becomming seperated. Indivudal #1 Assessment has been revised to include the full history, reviewed with the individual and shared with the team. All files have been reviewed to assure the presance of the Lifetime Medical History Attachment CCR # 1 ASsessment Cover Letter Ind ; Attachment : CCR # 2 Program Specialist Training. |
11/27/2019
| Not Implemented |
| 6400.181(e)(12) | Individual #1's 7/31/19 assessment did not include recommendations for services, training and programming. The assessment stated "no recommended trainings at this time, she has not requested any extra services, and that she attends other licensed program settings; a vocational and day program that does not pertain to the residential programming. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | An accurate and living assessment is critical in assessing the supports that indiviudals are recieving and how best to support them in getting the very best community life they can have. The failure to address these services is due to the fact that the Program Specialist answered the question from the agenccy perspective. The Program Specialist has reviewed and revised the individuals 7/31/19 assessment included information from the indiviudals perspective rather than the agency persepctive, believing we were to ask the indiviudal if they wanted any additional services, trainigns or programing. All program specialist have been educated to understand the purpose and point of view of these assessments areas from the agency perspective and reviewed other agency assessments for accuracy. Attachment CCR # 1 ASsessment Cover Letter Ind ; Attachment : CCR # 2 Program Specialist Training. |
11/27/2019
| Not Implemented |
| 6400.181(e)(13)(vii) | Individual #1's 7/31/19 assessment did not include an assessment of her ability to handle any money independently. Per staff report, the individual is given small amounts of money to carry independently. The individual's ISP states that she is able to carry no more than $20 with her due to her lacking money management skills. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| An accurate and living assessment is critical in assessing the supports that indiviudals are recieving and how best to support them in getting the very best community life they can have. Individual #1 has lived independently prior to admission to our facility. It is important to her that she be as independent as possible. The Program Specialist has reviewed and revised the individuals assessment to reflect her current support needs with regard to money managment. Attachment CCR # 1 ASsessment Cover Letter Ind ; Attachment : CCR # 2 Program Specialist Training. |
11/27/2019
| Not Implemented |
| 6400.212(b) | Individual #1's 4/1/19 physical examination contained pen mark additions to the physical after it was completed and faxed to the agency by the physician's office. Marks that were added included, an answer to the regulatory question asking if the individual was free from communicable disease and health maintenance needs were added onto the physical. The person making the entry did not sign and date their entries. | Entries in an individual's record shall be legible, dated and signed by the person making the entry.
| The physical in question was an admission physical and completed by another agency provided upon admission. Because the document was not signed and dated we do not know where the alteration occurred. Medical Coordinator's and Nursing staff have been educated on the proper handling of the indiviudals physical. No changes will be made to the document after having been signed by the physician. Referral documents must be complete prior to admission. The admission process did not include team members from medical who would be able to review the documentation for accuracy. Our Policy going forward is that an Admission Team consisting of members of each department will be responsible for review of admission materials. Attachment # 12: Admission Team Summary ; Attachment # 13 Admission Team Training |
11/27/2019
| Not Implemented |
| 6400.165(c) | Individual #1's record contains a physician order electronically signed by the individual's physician on 10/23/19 to start Cetirizine 10mg, take 1 tablet twice a day for 7 days, then twice a day as needed for rash and itching. The individual's 7AM dose on 10/24/19 was not administered. The medication administration record (MAR) was blank and there was no evidence to confirm that the individual was administered the medication as prescribed. The individual's mar also recorded that she was administered Cetirizine 10mg at 7PM and 7:19PM on 10/24/19 by staff #1. The individual did not have an order to administer this medication twice within 19 minutes of the previous administration. | A prescription medication shall be administered as prescribed. | A review of the Oct 2019 MAR for Ind #1 reveals that there were two orders for cetirizine this month. On 10/24/19 the order for Cetirizine "twice daily for rash or itch" on an as needed basis. The medication was administered at 8:50 am. Shortly after that administration the medication was ordered again with a scheduled administration which was labeled as "take 1 tablet by mouth twice daily for rash or itch". It does not appear to be an error but a MAR showing multiple entries for the same medication with different instructions The confusion is a relult of multiple orders for the cetirizine 10 mg. The electronic medication system is to automatically update MAR's when new orders are filled. The system does not work well when orders are changed and this must be done manually. To assure compliance all medication Upon review of the MAR we have discovered the following information. The Cetirizine 10 mg was prescirbed on 10/24/19 Take 1 tablet by mouth twice daily for rash or itch" as a PRN. The MAR shows a 8:50 am administration . After that administration the physician orders changed to a scheduled admin of Cetirizine Tab 10 mg Take 1 Tablet by mouth twice a day for rash or itch with admin time of 7 am and 7 pm. With the new order recived 10/24/19 AFTER the morning administration the medication was switched to a scheduled dose and the 7 PM dosage was given on 10/24/2019 at 7:19 PM. On 10/25/19 the medication scheduled administration time of 7 am and 7 pm. Records show a late am administration (9:01 am) but while it was late it was not an overdose. The medication was given as prescribed on 10/24/19 and 10/25/19 only two doses with one being a late administration. Medications were not administered within 19 minutes of each other. The late administration of this medication was addressed in regulation 6400.166 (a) (10). Attachment CCR # 6 Oct 2019 MAR ; Attachment CCR #7 Care History Ind # 1 both demonstrate the administration times. |
11/27/2019
| Not Implemented |
| 6400.165(f) | The individual's 6/14/19 seen plan only addressed her diagnosis of schizophrenia. The individual is prescribed medications for depression, anxiety, mood disorder, psychosis, agitation, schizophrenia along with neurocognitive diagnosis that weren't addressed in this plan of support. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | The Social, Emotional and Enviornmental plan is a guide for staff to safely support the individual with their mental health needs. The Program Specialist is responsible for assuring that all mental health diagnosis are addressed in the SEE plan. In the future all SEE plans will be reviewed by the Program Specialist Supervisor to assure that all mental health diagnosis are included. The Program Specialist has reviewed and updated the SEE plan to assure we have a compresensive document. The SEE plan is written in conjuction with the Assessment and distributed to the team in order to keep people informed. Attachment CCR # 11 Social Emotional Environmental Plan ; ; Assessment # 3 Training for staff. |
11/27/2019
| Not Implemented |
| 6400.165(g) | The individual's 10/3/19 psychiatric medication review did not have the complete names of the medications for celexa, Aricept, Namenda, risperidone and Topamax. Half of the medication names were cut off. The dosage for risperidone was not included in this medication review. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Medication Managment must be accurate and timely to assure personal safety of people we support. The psychiatric review assures that people are recieving the medications they need to manage mental health diagnosis. A review of the document in question reveled that the EXCEL document had a text box shift so that it obsucured half of the list of medications when it was printed. Medical Coordinator's have been educated to understand the importance of having a clear list of medications for the physician to review. Following all 3 month reviews and prior to filing in the individuals file it will be reviewed by the Medical Coodinator Supervisor to assure compliance. Attachment: CCR # 10 3 month review; Attachment CCR # 5 Medical Department Training. |
11/27/2019
| Not Implemented |
| 6400.166(a)(7) | On 10/23/19, Individual #1's primary care physician electronically ordered Cetirizine 10mg tablet, take 1 tablet twice a day for 7 days, then twice a day as needed for rash and itching. The individual's October medication record did not match the physician's order. The medication record stated, "cetirizine tab 10mg, take 1 tablet by mouth twice daily for rash or itch," and also, "cetirizine tab 10mg take 1 tablet by mouth twice daily as needed for rash or itch." | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | Medication Managment must be accurate and timely to assure personal safety of people we support. A review of the Oct 2019 MAR for Ind #1 reveals that there were two orders for cetirizine this month. On 10/24/19 the order for Cetirizine "twice daily for rash or itch" on an as needed basis. The medication was administered at 8:50 am. Shortly after that administration the medication was ordered again with a scheduled administration which was labeled as "take 1 tablet by mouth twice daily for rash or itch". It does not appear to be an administration error but a MAR showing multiple entries for the same medication with different instructions The confusion is a result of multiple orders for the same medication in a electronic system that is designed to update with each order but appears to have some problems with the process. To assure accurate documentation all medication labels and Medication Administration Records will be reviewed and compared at the medical office by the Medical Coordinators and / or Nursing staff and manually changed with close attention to new orders, Multiple orders and changes in orders may result in errors between the order, label, and MAR. Attachment: CCR - # 10 Accurate Medication Labels; Attachment CCR : # 5 Medical Dept Training |
11/27/2019
| Not Implemented |
| 6400.166(a)(10) | Individual #1's 10/25/19 medication administration record (mar) recorded that staff #1 administered cetirizine 10mg at 7am and 7pm but also listed that staff #1 administered the same medication on 10/25/19 at 9:01am and 7:13pm. The agency did not know if the medication was not initialed for the correct time or if it wasn't administered per directions. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | Medication Managment must be accurate and timely to assure personal safety of people we support. The review of the medication administration records show Cetirizine 10 mg administered on 10/24/19 at 8:50 am. This order was a PRN. At some point on 10/24/19 AFTER the PRN morning administration at 8:50am the physician changed the order to a scheduled administration 2 x per day at 7 am and 7 pm. Staff now follows the new order, aware it has been administered that morning as a PRN now is SCHEDULED to be administered at 7 PM. Staff administered the medication at 7:19 pm on 10/24/19. The Care Plan shows more clearly that on 10/24 and 10/25 only two administrations of cetirizine were given which matches the physician orders. On 7/25/19 Cetirizine (now prescribed with a schedled administration of 7 am and 7 pm is administered at 9:01 am and 7:13 pm. The medication has been administered only two times each day with no extra administrations. Upon review it initially appeared that 10/25/19 AM admin which occured at 9:01 Am was administered late by one hour. Because Individual # 1 frequently chooses to sleep in, her physician has authorized an additional hours administration in the morning medications which allows staff to administer medications up to 9 am. ( + or - 1 min for internet lag means 9:01 would not be late). It appears these medications are administered correctly and with the extra hour of admin time staff just barely met the extended administration time. Had Staff not had an extended admin time in the morning we would be completing a medication error and subject to disciplinary action. At the present time the current policy is that any staff who make a Medication Error will attend our quarterly refresher course for Medication Administration. Any staff completing this error are subject to the participating in quarterly retraining for any medicaition errors and in addition subject to the Medication Write up policy. Chronic failure to use the system will result in disciplinary action which can include loss of medication administration privledges. Nursing staff will notify Human Resourse with information regarding the staff persons past practices and use of the system. To assure a through understanding of the regulations , by January 2020 all staff administering medications will complete a Medication Administration refresher course. All medications will be reviewed for accuracy. Attachment: CCR # 6 Oct 2019 MAR; Attachment: CCR # 7 Care History ; Attachment : CCR # 8 Medicaition Admin write up policy. Attachment : CCR # 9 Medical Dept Training |
11/27/2019
| Not Implemented |
| 6400.166(b) | Staff #1 recorded a note on Individual #1's 11/3/19 medication administration record that she administered Thyroid medication to the individual at 7am but did not sign as administered until 8:07am.
Staff #1 recorded a note on Individual #1's 11/3/19 medication administration record (mar) that she administered the individual's 8am medications (citalopram, carbamazepin, Topiramate, Risperidone, Clonazepam, Memantine, Vitamin b-6, Vitamin d3, flora assist heart health probiotic, super omega cap, donepezil, solifenacin, fluticasone, famotidine) but forgot to sign off as administering them until 12:48pm.
Staff #1 recorded a note that she administered medications to the individual at 7:30pm on 11/9/19 but did not sign as administering the medications until 8:17PM (for meds: carbamazepin, risperidone, memantine, flora assist heart health probiotic, super omega cap, clonazepam).
Staff #1 recorded a note on 11/10/19 that she administered thyroid at 7am but did not sign the medication log until 9:05AM.
Staff #1 recorded a note that she administered thyroid and Provigil at 6:30am but did not sign as administering the medication until 7:04am on 10/11/19 | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Medication Administration must be completed accurately and on time in order address health and safety needs of people we support. In May 2019 we switched to an electronic system which requires a process for staff to log administration immediately upon delivery of medication. Nursing are alerted when staff do not complete the MAR sign off in a timely manner. Nursing will contact staff to alert them of the pending documentation and will review the prior month for any additional documentation failures. Any staff having a medication error in the quarter will attend a medicaion refresher course held each quarter. Chronic failure to use the system or refusing to attend quarterly refressher course will result in disciplinary action which can include loss of medication administration privledges. Nursing staff will notify Human Resourse with information regarding the staff persons past practices and use of the system. Attachment: CCR # 4 Disciplinary Policy for Medication Nursing policy Attachment: CCR # 5 Medical Dept Training |
11/26/2019
| Not Implemented |
| 6400.186 | Individual #'1's ISP states that she is able to carry no more than $20 with her due to her lacking money management skills. On 9/29/19, the individual was documented as being given $50 by staff. | The home shall implement the individual plan, including revisions. | Money management skills need to be documented clearly so that the indiviudal and staff can use month in the community without fear of loss of funds. The ISP states that "Dad recommends Individual #1 not carry in excess of $20. This Indiviudal lived on their own prior to placement and was accustomed to carrying larger amounts of cash. The event in question was a special Harvest Fest event and staff provided funds as per family without referring to the ISP assessed safe carry amount. The Program Specialist is responsible for completing an updated assessment with special attention to financial money managment. The updated assessment will be shared with the team in order to assure compliance with assessed needs. The Program Specialist is responsible for educating the staff on the assessed level of care. Attachment: CCR # 1 Assessment cover letter Attachment: CCR # 2 Assessment Revision for Individual 1 Attachment CCR # 3 Training Record |
11/27/2019
| Not Implemented |