| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The Fish Tank in individual #1 bedroom needs cleaned. It is full of a significant amount of algae growth that covered the tank you cannot see the fish. There was also a slimy film covering the filter. | Clean and sanitary conditions shall be maintained in the home. | It is important to maintain clean and sanitary conditions in the home. If House Supervisor discovers any issues with the fish tank a Maintenance Order will be completed to schedule cleaning of the tank. House Supervisors were informed on the process. Attachment T-1 , T-2 Training Log and Summary |
10/25/2019
| Implemented |
| 6400.141(c)(11) | Individual #2 physical 5/8/19 the health maintenance needs section was blank. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The Indiviudal Physical form must include a space or blanks for physicians to review and respond to health maintenance needs for the individual. Medical Support staff were educated on the contents of this section of the physical in order to assist the physician in understanding and completing this section. Medical Support Coordinator will assure completion of the physicial. The Medical Support Supervisor will review all physicials to assure completion. All records are reviewed for accuracy. Attachment : T-1 , T-2 Training Log and Summary |
10/25/2019
| Implemented |
| 6400.144 | Individual #2 has a specific Bowel Movement Protocol she is to follow per her physician's orders. There were none of the prescribe medications relating to this Bowel Movement Protocol at individual #2 home during this unannounced monitoring. The medications that were not available at individual #2 home per her Bowel Movement Protocol included: Milk of Magnesia ,Dulcolax, and Fleet Saline Laxative Enema. Please note these medications were filled and at the individual #2 home on 9/20/19. | 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.
| Medications that are PRN and prescribed routinely must be present at the facility in order to be able to administer when needed. Medical Support staff and Nurses have been educated on the need to have medication present at the facility. All records are reviewed to assure compliance. Attachment: D: Photo of Protocol Medications; T-1, T-2 Training Log and Summary |
10/25/2019
| Not Implemented |
| 6400.163(a) | The following medications for individual #2 did not have a label issued by pharmacy:
· Citracal Maximum Plus Caplets
· Cetirizine Hydrochloride tablets 10mg
· Nasacorcort Allergy 24hour | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | Medications must have clear directions in order to be safely used. When over the counter medications are prescribed in a manner different than the label instructions there must be a pharmacy label on the medication with instructions for staff. Medical Support Supervisor and Nursing staff are responsible for assuring that any prescription medications have a pharmacy label. All medications come from the pharmacy each month to the medical office. The information on the MAR will be compared to the information on the label for accuracy. The medical staff will review all medication and make corrections on the Electronic Record prior to the medication being dispensed to the home. All records were reviewed for compliance. Attachment A: Electronic MAR Instructions B-1, b-2,B-3 Photo of Medication Labels |
10/25/2019
| Not Implemented |
| 6400.163(h) | Individual #2 Nystatin Ointment 30mg apply liberal to the affected area three times a day X7 days filled 8/5/19.
This medication should have been discarded per Mattern House policy after individual completed the ordered regimen per her doctor, Also considering the fact that this medication was not discarded per policy, EIM incident #8586416 is a result of staff applied the medication at 7pm 8/12/19 and last dose to be applied was 12n 8/12/19. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Discontinued medication must be removed from the property promptly to ensure that there is no medication present to cause an error. All homes have been notified that discontinued medications must be sent to the medical office within 48 hours. A protocol has been developed and provided to staff. The nursing and medical staff are responsible for assuring that all discontinued meds are recieved within 48 hours. All records are reviewed to assure compliance. Attachment: C - Discontinued Medication Process |
10/25/2019
| Not Implemented |
| 6400.166(a)(4) | The following medication does not match individual #1 September 2019 Medication Administration Record: The medication states: Citracal Max Cap 180's,take two tabs by mouth everyday.
September Medication Administration Record states: Citrical Maximum Plus, take one tab by mouth two times a day, 1 tab in AM, 1 tab in the PM, (family provides) supplement. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | The medication name should match the medication records. The family has been responsible for purchasing the OTC medication and has frequently changed brands based on price. The current plan is that all OTC medication will be obtained through a pharmacys that provides a label which is reviewed by the medical staff. Any brand changes will be immediatly reflected on the MAR. The protocol for 6400.166(a)(7) will also impact this regulation - where all labels are reviewed monthly for accuracy. All records are reviewed to assure compliance. Attachment: A: Electronic MAR Instructions B-1, b-2,B-3 Photo of Medication Labels |
10/25/2019
| Not Implemented |
| 6400.166(a)(7) | The following medication does not match individual #1 September 2019 Medication Administration Record: The medication states: Citracal Max Cap 180's,take two tabs by mouth everyday.
September Medication Administration Record states: Citrical Maximum Plus, take one tab by mouth two times a day, 1 tab in AM, 1 tab in the PM, (family provides) supplement. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | The Medication Administration Record is an electronic record on the Exended Care Professional program. All medications come from the pharmacy each month, When medication arrive at the central office each month they are reviewed. The information on the MAR will be compared to the information on the label for accuracy. The medical staff will review all medication and make corrections on the Electronic Record prior to the medication being dispensed to the home. All records have been reviewed to assure compliance. Attachment: A: Electronic MAR Instructions B-1, b-2,B-3 Photo of Medication Labels |
10/25/2019
| Not Implemented |