| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.24(d)(1) | Individual #1's monthly financial records kept at the home, do not document the specific funds received by and deposited into the individual's home account. Each month, $250 dollars is documented as being added to said funds within the first few days of the month. However, the specific check that was deposited is not recorded. According to the individual's bank account managed by the agency, Compass Community Connections, there is more than one check written to Individual #1's family living provider monthly to deposit into the individual's account. It is unknown if all funds are being deposited into the individual's monthly spending account due to the inadequate documentation. | An up-to-date financial and property record shall be kept for each indivudal that includes the personal possessions and funds received by or deposited with the family or agency. | CCC acts as the Representative Payee for Individual #1. This regulation is important for the integrity of CCC and Family #1 in their handling of Individual #1s finances. During the exit interview held on 11/10/21, the wording of CCCs life sharing contract was called into question. However, the written citation received does not reflect this and instead explains how Individual #1 receives their Petty Cash each month and how Individual #1 pays Family Member #1 for their room and board. CCC will obtain a debit card for this individuals bank account and have the Family member assist this individual with making withdrawals for petty cash purchases. |
02/01/2022
| Implemented |
| 6500.71 | The emergency telephone numbers to the nearest hospital, police department, fire department, ambulance and poison control center were not located on or by the only telephone in the home, the kitchen telephone. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home. | This regulation is important because emergency telephone numbers need to be readily accessible to staff so that Individual #1 can maintain their safety.
The emergency telephone numbers were located on the telephone but had rubbed off of the sticker due to repeated use of the telephone.
No back up emergency telephone number stickers were provided to the staff to replace the one that had rubbed off.
The Life Sharing Specialist Printed New Emergency Telephone number stickers and provided ten extra stickers for staff to keep as replacements. |
11/23/2021
| Implemented |
| 6500.107(d) | The smoke detectors in the home were not checked in December 2020. The home reported that the smoke detectors in the home were checked on 11/24/2020 and not again until 1/1/2021. | A smoke detector shall be tested each month to determine if the detector is operative. | This regulation is important to ensure the safety of individual #1 in the event of a fire at their residence.
The smoke detectors were checked twice in January 2021 instead of once in December and once in January.
The annual fire safety training was held the morning of January 1, 2021 which included a smoke detector check. This put the home out of compliance by a few hours.
The Life Sharing Specialist reminded the provider that the smoke detectors need to be checked each month. |
11/26/2021
| Implemented |
| 6500.109(f) | According to fire drill records the front door was the only egress door used to exit the home during fire drills held from 7/18/2020 to 7/2/2021. | Alternate exit routes shall be used during fire drills. | This regulation is important to ensure that safety of individual #1 in the event of a fire at their residence.
The front door was used during the last several fire drills in the home.
The Life Sharing Provider utilized the exit closest to where Individual #1 was at the time of the fire drills.
The Life Sharing Specialist requested a fire drill be held immediately with the kitchen door being the utilized exit. |
12/02/2021
| Implemented |
| 6500.121(c)(3) | Individual #1's 12/1/2020 physical examination record did not include their list of immunizations to include all CDC recommended immunizations. The 12/1/2020 record stated a list of immunizations for Individual #1 was attached, however, nothing was attached to the record. | Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | This regulation is important to ensure that individual #1 is protected against preventable illness.
Individual #1s physical form from 12/1/2020 stated that the immunization records were attached. When submitted for licensing, no such record was attached.
The immunization record was filed separately from the physical.
The Life Sharing Specialist located Individual #1s immunization record. |
12/02/2021
| Implemented |
| 6500.121(c)(4) | Individual #1's 12/1/2020 physical examination record did not include an annual vision and hearing screening. The 12/1/2020 record stated vision and hearing screenings were unable to be assessed by the physician. The 12/1/2020 record did not include the date or results of the last known vision and hearing screenings or record of deferment from a physician. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | This regulation is important to ensure that Individual #1s physicals encompass all aspects of their health.
Individual #1s physical from 12/1/2020 did not include a vision or hearing screening.
Individual #1 is legally blind and does not communicate verbally, making it challenging for the family physician to complete these screenings.
Individual #1 had their annual physical on 12/2/2021. The physician was asked to complete a vision and hearing screening that was adapted to Individual #1s specific needs. |
12/08/2021
| Implemented |
| 6500.121(c)(15) | Individual #1's 12/1/2020 physical examination did not include all dietary instructions to maintain the individual's safety while ingesting food.
· According to the agency, Compass Community Connections, via their individual identification sheet they must only ingest nickel-sized bites.
· According to the agency's Health Risks Protocols for Individual #1, they are to eat nickel-sized bites, small portions, allow the individual to chew and swallow before the next bite, soft foods are preferred as they are at risk of choking on harder food items like hard candies or steak, avoid popcorn and sticky foods, Individual #1 has a hard time eating peanut butter so this must be avoided, when they are unable to complete 50% of their meal or less they may be supplemented with one can of Pedisure, and can be given up to 3 cans per day for their three meals.
· Individual #1's 12/1/2020 physical examination record only stated they could have Pedisure 1-3 cans by mouth daily for supplement and small bites/portions.
· Individual #1's individual support plan stated they are able to eat quarter-sized bites, small portions, should avoid hard foods like candies or steak due to risk of choking, takes Pedisure as needed but also includes all information from the individual's health protocol document.
There are no records that the individual's physician was contacted to clarify the individual's dietary needs to prevent potential choking incidents. | The physical examination shall include: Special instructions for the individual's diet. | This regulation is important to ensure that Individual #1s physicals encompass all aspects of his health.
Individual #1s physical from 12/1/2020 did not include any dietary instructions.
Individual #1s physician did not fill in this section and the Life Sharing Specialist/Provider did not seek clarification from the physician regarding dietary instructions.
Individual #1 had their annual physical on 12/2/2021. The physician was asked to complete this section of the physical. |
12/08/2021
| Implemented |
| 6500.151(e)(2) | Individual #1's 2/8/2021 assessment does not include their dislikes. The section titled, "likes, dislikes, and interests of the individual" did not include any dislikes. The individual's assessment does state that they may bang their head on the ground if upset or overstimulated but doesn't describe what the individual may dislike causing them to bang their head on the ground. | The assessment must include the following information: The likes, dislikes and interest of the individual. | This regulation is important to ensure that everyone involved in Individual #1¿s care knows about the likes and dislikes of the individual.
Individual #1¿s assessment stated that he may bang his head if upset or overstimulated but did not describe what may cause the individual to do this.
Individual #1¿s assessment did not go into enough detail about the likes and dislikes of the individual.
The Life Sharing Specialist wrote an addendum to the assessment with an update to this section. |
12/02/2021
| Implemented |
| 6500.151(e)(4) | Individual #1's 2/8/2021 assessment states the individual cannot be left alone in their home for any extended period of time; allowing for shorter periods of time when this could occur. However, Individual #1 requires full assistance with evacuation of the home in the event of an emergency and cannot be left home alone for any period of time. | The assessment must include the following information: The individual's need for supervision. | This regulation is important to ensure that the assessment accurately describes the needs of Individual #1.
Individual #1s assessment stated that the individual cannot be left alone in their home for any extended period of time which left open for interpretation that he may be allowed to be left alone for shorter periods of time. However, Individual #1 requires full assistance with evacuation of the home and cannot be left alone for any period of time.
The wording in this section was meant to imply that the individual can not be left alone for any period of time, but the wording needs to be clearer.
The Life Sharing Specialist wrote an addendum to the assessment with an update to this section. |
12/03/2021
| Implemented |
| 6500.151(e)(9) | Individual #1's current, 2/8/2021 assessment does not include all of their functional and medical limitations.
· Individual #1's neurologist instructed the individual to use a helmet due to their seizures on 3/25/21. The use of the helmet isn't included in the individual's assessment.
· The individual uses and requires a handicapped accessible shower and shower chair on wheels. The individual's assessment states the home is still gathering bids to have the shower remodel completed. During the 11/9/21 inspection of the home, the shower remodel to include a handicapped accessible shower with shower chair had been completed for months. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | This regulation is important to ensure that the assessment accurately describes the needs of Individual #1.
Individual #1s assessment stated that the neurologist instructed the individual to wear a helmet due to seizures the use of the helmet was not included in the assessment.
The assessment stated that Individual #1 requires a handicap accessible shower and shower chair. The assessment stated that bids were being gathered for this project to be completed ¿ upon the 11/8/2021 inspection, this project was completed but was not reflected in the assessment.
The Life Sharing Specialist was not writing addendums to the assessment that would reflect the updates of Individual #1¿s functional and medical limitations.
The Life Sharing Specialist wrote an addendum to the assessment with an update to this section. |
12/03/2021
| Implemented |
| 6500.151(e)(10) | Individual #1's 2/8/2021 assessment didn't include their lifetime medical history. The assessment stated the lifetime medical history was attached to the assessment, but none was provided. | The assessment must include the following information: A lifetime medical history. | This regulation is important to ensure that the assessment accurately describes the needs of Individual #1.
Individual #1¿s assessment stated that Individual #1s lifetime medical history was attached to the assessment. The lifetime medical history was not uploaded with the assessment for the 11/8/2021 inspection.
The assessment and lifetime medical history documents were not filed together and therefore not uploaded together.
The Life Sharing Specialist obtained a copy of the lifetime medical history. |
12/08/2021
| Implemented |
| 6500.151(e)(13)(ii) | Individual #1's 2/8/2021 assessment does not include their current level of skills and progress made over the previous 365 days in motor and communication skills. The individual's 2020 and 2021 assessments were verbatim in these areas, thus not assessing their current abilities and progress over the previous 365 day. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | This regulation is important to ensure that the assessment accurately describes the needs of Individual #1.
Individual #1s 2021 assessment was verbatim in the section assessing their progress and current skill level for motor and communication skills.
The Life Sharing Specialist did not rewrite this section of the assessment.
The Life Sharing Specialist wrote an addendum to update this section of the assessment. |
12/06/2021
| Implemented |
| 6500.151(e)(13)(iii) | Individual #1's 2/8/2021 assessment does not include their current level of skills and progress made over the previous 365 days in activities of residential skills. The individual's 2020 and 2021 assessments were verbatim in these areas, thus not assessing their current abilities and progress over the previous 365 days. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | This regulation is important to ensure that the assessment accurately describes the needs of Individual #1.
Individual #1s 2021 assessment was verbatim in the section assessing their progress and current skill level for activities of residential living.
The Life Sharing Specialist did not rewrite this section of the assessment.
The Life Sharing Specialist wrote an addendum to update this section of the assessment. |
12/06/2021
| Implemented |
| 6500.151(e)(13)(iv) | Individual #1's 2/8/2021 assessment does not include their current level of skills and progress made over the previous 365 days in personal adjustment skills. The individual's 2020 and 2021 assessments were verbatim in these areas, thus not assessing their current abilities and progress over the previous 365 days. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Personal adjustment. | This regulation is important to ensure that the assessment accurately describes the needs of Individual #1.
Individual #1s 2021 assessment was verbatim in the section assessing their progress and current skill level for personal adjustment skills.
The Life Sharing Specialist did not rewrite this section of the assessment.
The Life Sharing Specialist wrote an addendum to update this section of the assessment. |
12/06/2021
| Implemented |
| 6500.151(e)(13)(v) | Individual #1's 2/8/2021 assessment does not include their current level of skills and progress made over the previous 365 days in socialization skills. The individual's 2020 and 2021 assessments were verbatim in these areas, thus not assessing their current abilities and progress over the previous 365 days. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | This regulation is important to ensure that the assessment accurately describes the needs of Individual #1.
Individual #1s 2021 assessment was verbatim in the section assessing their progress and current skill level for socialization skills.
The Life Sharing Specialist did not rewrite this section of the assessment.
The Life Sharing Specialist wrote an addendum to update this section of the assessment. |
12/06/2021
| Implemented |
| 6500.151(e)(13)(vi) | Individual #1's 2/8/2021 assessment does not include their current level of skills and progress made over the previous 365 days in recreation skills. The individual's 2020 and 2021 assessments were verbatim in these areas, thus not assessing their current abilities and progress over the previous 365 days. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | This regulation is important to ensure that the assessment accurately describes the needs of Individual #1.
Individual #1s 2021 assessment was verbatim in the section assessing their progress and current skill level for recreation skills.
The Life Sharing Specialist did not rewrite this section of the assessment.
The Life Sharing Specialist wrote an addendum to update this section of the assessment. |
12/06/2021
| Implemented |
| 6500.151(e)(13)(ix) | Individual #1's 2/8/2021 assessment does not include their current level of skills and progress made over the previous 365 days in community integration skills. The individual's 2020 and 2021 assessments were verbatim in these areas, thus not assessing their current abilities and progress over the previous 365 days. The 2021 assessment stated the individual was making progress in areas of community integration but did not include evidence of the progress made. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Community integration. | This regulation is important to ensure that the assessment accurately describes the needs of Individual #1.
Individual #1s 2021 assessment was verbatim in the section assessing their progress and current skill level for community integration skills.
The Life Sharing Specialist did not rewrite this section of the assessment.
The Life Sharing Specialist wrote an addendum to update this section of the assessment. |
12/06/2021
| Implemented |
| 6500.124 | There are multiple times over the previous year, November 2020-November 2021 that health services for Individual #1 were not provided. The following are examples of the home failing to ensure said services were provided to Individual #1.
· Individual #1 had a dental appointment on 10/31/2019 and was to return on 5/5/2020, every 6 months. On 6/23/2020 the home indicated that the 5/5/2020 appointment was cancelled due to COVID-19 and that Family member #1 will follow up to see when it can be rescheduled. There are no records maintained that the home attempted to schedule the dental appointment for Individual #1 until 9/3/2020. Additionally, there are no records maintained that the home spoke to Individual #1's dental office to schedule an appointment. Family member #1 documented they only contacted the dental office answering service on 9/4/2020.
· Individual #1 did not return to their dentist until 6/17/21 for a visual examination. Individual #1's 6/17/21 dental examination did not include a dental cleaning as required for 6500.122(d).
· Individual #1's physician recorded on the individual's 12/1/2020 physical examination records that Pediasure is to be administered as 1-3 bottles daily, and 1-3 bottles daily as needed. There are no records maintained that the home obtained clarification for how and when to administer this supplement. The home was administering Pediasure as needed for the previous year.
· Individual #1 has a seizure protocol that instructs staff and family members to time the seizure, as 911 needs to be called in the event Individual #1 has a seizure lasting more than 5 minutes or multiple seizures in a row. According to Family member #1 on 2/4/21, they contacted the individual's physician on 2/4/21 due to the individual experiencing multiple seizures and did not call 911. Additionally, Family member #1 documented that Individual #1 experienced 14 seizures from 9:20am-4:14pm before they contacted any medical professionals, and Individual #1 experienced two additional seizures after leaving a message with the individual's physician office at 4:30pm on 2/4/21.
· Individual #1's same seizure protocol instructs staff and family members to time the seizure, as 911 needs to be called in the event Individual #1 has a seizure lasting more than 5 minutes or multiple seizures in a row. The time of seizure documented by staff and family members in February 2021, 3/4/21, 3/5/21, 3/8/21, and 5/16/21 documented a range of seconds of how long the seizure supposedly lasted, i.e. 5-10 seconds, 5-6 seconds. Additionally, Family member #1 documented on 5/5/21 that sometime in the morning, Individual #1's seizure was "? Brief", they administered Clonazepam and that another agency informed Family member #1 that the other agency witnessed multiple seizures. The individual's seizure protocol was not implemented, and medical professionals were not contacted to ensure the individual's safety was maintained.
· Individual #1's seizure protocol states if the individual does not return to baseline after a seizure, 911 must be called. Staff documented Individual #1 had seizures on 5/5/21 and 5/31/21, Clonazepam was administered both times, and there are no records that the individual returned to baseline. There are no records that 911 was notified or medical professionals were contacted.
· Individual #1 was taken by ambulance to the Emergency room on 3/16/21 due to seizures they were experiencing at day program. The home was provided discharge instructions stating to follow-up with the individual's neurologist tomorrow to discuss further management and possible medication adjustment based on the Tegretol level drawn today. There are no records that the home followed up with the individual's neurologist until 3/25/21.
· On 3/25/21 Family member #1 recorded that Individual #1's neurologist wants to complete an EEG, requiring an overnight stay, to monitor the individual's seizures. At the time of the 11/8/21 inspection, there are no records that the individual returned to have the EEG completed.
· Individual #1 was prescribed Levetiracetam 500mg at their 6/10/21, 9:32am appointment due to an increase in their seizures over the previous months. The individual did not receive the first dose of this medication until 6am on 6/12/21.
· On 6/10/21 Individual #1's neurologist stated to continue to track seizure events and note the individual's behaviors during them, and if rescue medication was administered. Staff administered rescue medication, Clonazepam, in the evening on 7/9/21 but there are no records of Individual #1's seizures in July 2021 or documentation of when or why the Clonazepam was administered.
· On 9/17/21 Individual #1's neurologist stated to contact the neurologist if "Individual #1 has appetite problems again, could try liquid Keppra or have family physician try appetite stimulant medication." The individual's health plan states to administer Pediasure if the individual has eaten 50% or less of their meal to administer the supplement. Staff and family members have administered Pediasure morning and evening, daily over the previous year, and occasionally administer the supplement at noon. At the time of the 11/8/21, there are no records that the individual's neurologist or family physician was notified of the individual's continued suppressed appetite.
· As described throughout this report, Polymxin B sulfate & Trimethoprim Ophthalmic Solution (or a version of this medication's name recorded on Individual #1's mars; Polyeye drops, Polymyxin B-tmp and Polymyrin eyes) was administered to Individual #1 multiple times after February 2021. During the 11/9/21 onsite inspection, the medication label stated the medication expired in February 2021. Family member #1 confirmed during the inspection that the expired medication was the only Polymxin eye drop medication at the home over the previous year and the only Polymxin eye drop administered to the individual. Additionally, the medication label found at the home, not attached to the Polymxin medication, stated to dispose of the medication by 12/1/2020. | 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. | This regulation is important to ensure the health and safety of Individual #1.
There were several occasions throughout the year where the Life Sharing Provider communicated with Individual #1s doctor but did not document the communication. Individual #1s seizure protocols were not followed by the Life Sharing Provider.
The Life Sharing Provider was forgetting to document in writing the phone conversation she was having with Individual #1s doctor. Individual #1s seizure protocol and health risk protocol need reviewed.
The Life Sharing Specialist instructed the Life Sharing Provider to document in writing all verbal communication they have with Individual #1s doctor. Individual #1s seizure protocol on their health risk protocol will be updated. |
12/06/2021
| Implemented |
| 6500.17(a) | REPEAT from 11/23/2020 annual inspection: The home did not complete a self-assessment of 6500.68(b) and 68(c), 3-6 months prior to the agency's license expiration date. The self-assessment completed for the home did not include results for 68(b) and (b), the fields were left blank. | If an agency is the legal entity for the home, the agency shall complete a Self-Assessment of Homes the agency is licensed to operate within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. | This regulation is important to help the agency be aware of all potential regulation violations.
When the self-inspection was completed, the water temperature was not checked/documented.
This occurred due to an oversight by the Life Sharing Specialist who completed the self-inspection.
The water temperature was checked and found to be at an appropriate temperature during the 11/8/2021 inspection. |
01/31/2022
| Implemented |
| 6500.20(b)(2) | The medication errors described in 6500.135(c) and 6500.137 of this report were never reported to the Department's information management system. | The agency and 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 § 6500.136 (relating to medication errors), if the medication was ordered by a health care practitioner. | This regulation is important to help the agency and the Life Sharing Provider remain accountable for medication errors and ensures the safety of Individual #1 when taking their medication.
Some medication errors occurred and the Light Sharing Provider did not report them to the agency within 72 hours therefore no incidents were filed regarding these medication errors.
The Life Sharing Provider did not identify medication errors that occurred. The agency receives MARs at the end of each month meaning that the medication errors were not reported within 72 hours.
The Life Sharing Provider will complete a new medication administration training so that she can review what medication errors are and what to do when one occurs. |
12/07/2021
| Implemented |
| 6500.32(s) | Individual #1's record did not include information if the individual wanted to have a key or entry mechanism to access an entry door of their home or if they chose to refuse that right. | An individual has the right to have a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of the home. | This regulation is important to ensure Individual #1s safety.
Documentation was never established of whether Individual #1 was offered an entry mechanism to their home, or if they refused their right.
Individual #1 is legally blind, non-verbal, and lacks the fine motor skills to use a key or other entry mechanism to his home. Therefore, he cannot accept or reject the option to have access to an entry mechanism.
Individual #1s physician is writing an explanation of why it is not feasible for them to have an entry mechanism to their home. |
12/08/2021
| Implemented |
| 6500.45(a) | The agency, Compass Community Connections, could not produce any documents to indicate that Family member #1 was trained by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid and Heimlich techniques annually. The agency produced documentation showing Family member #1 was trained in first aid on 1/9/21 but did not have records of any first aid training prior to. | The primary caregiver shall be trained by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid and Heimlich techniques prior to an individual living in the home and annually thereafter. | This regulation is important to ensure Individual #1s safety.
Family Member #1 is trained in first aid and Heimlich techniques, and has been prior to her current certification but the agency did not have certification cards to prove this.
The agency has training records dating back to Family Member #1s first aid and Heimlich trainings beginning in 2017 however no official certification cards are on file. |
12/07/2021
| Implemented |
| 6500.45(b) | The agency, Compass Community Connections, could not produce any documents to indicate that Family member #1 was trained by an individual certified as a trainer by a hospital or other recognized health care organization, in cardiopulmonary resuscitation (CPR) techniques annually. Individual #1's record indicates they are a choking risk and have a modified diet due to choking risks while eating. The individual also experiences multiple seizures per month and is prescribed a rescue medication to be administered during seizure events. The agency produced documentation showing Family member #1 was trained in CPR on 1/9/21 but did not have records of any CPR training prior to. | The primary caregiver shall be trained and certified by an individual certified as a trainer by a hospital or other recognized health care organization, in cardiopulmonary resuscitation, if indicated by the medical needs of the individual, prior to the individual living in the home and annually thereafter. | This regulation is important to ensure Individual #1s safety.
Family Member #1 is trained in CPR and has been prior to her current certification but the agency did not have certification cards to prove this.
The agency has training records dating back to Family Member #1s CPR trainings beginning in 2017 however no official certification cards are on file.
The Life Sharing Specialist will upload the 2017 and 2019 training logs with dates for CPR certifications on it, as well as reaching out to the trainer to obtain official certification cards for these trainings. |
12/07/2021
| Implemented |
| 6500.49(a) | The agency, Compass Community Connections, purported that Family member #1 received trainings on 4/13, 4/20, and 4/27. However, Family member #1's training records didn't include the training source, content, the year of completion, length of training, or copies of certificates received and persons attending for any of the purported trainings.
The entire training record for Family member #1 did not include the content for all training recorded. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and persons attending, shall be kept. | This regulation is important to ensure that Family Member #1 is accurately trained per the 6500 regulations.
Family Member #1 participated in the agency's annual trainings on 4/13, 4/20, and 4/27/2021. The date, trainer, topic, and hours were recorded on Family Member #1s training log but the agency did not upload the entire training that was completed.
This occurred due to an oversight by the agency, thinking that Family Member #1s training record would be sufficient documentation.
The Life Sharing Specialist uploaded the full training that was completed on these dates. |
12/08/2021
| Implemented |
| 6500.133(a) | Polymxin B sulfate & Trimethoprim Ophthalmic Solution was not stored in its original container. The medication bottle was stored in the kitchen cabinet and the family member located the original container for the medication in the individual's bedroom. Also, the prescription medication bottle did not contain a label issued from the pharmacy. The label issued from the pharmacy was also located in the individual's bedroom. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | This regulation is important to ensure that Individual #1 is being administered their medications safely and correctly.
Family Member #1 separated the eye drop bottle from the original container and the label. The eye drop bottle was located in the kitchen while the original container and the label were located in Individual #1s bedroom.
This occurred due to an oversight by Family Member #1.
Family Member #1 was retrained in medication administration as a refresher in how to safely and correctly store medication. |
12/07/2021
| Implemented |
| 6500.133(h) | At Individual #1's 12/1/2020 physical examination appointment, the physician prescribed Claritin and Tylenol as needed. During the 11/9/21 inspection at the home, Tylenol Pm had expired in July 2021 and Equate allergy expired in December 2020. The home didn't have other Tylenol or allergy medications available to Individual #1. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | This regulation is important to ensure that Individual #1 is not being administered expired medication.
Family Member #1 was storing expired Claritin and Tylenol that was to be used as needed for Individual #1.
Individual #1 never used this medication after it was bought, resulting in the expiration dates never being checked.
Family Member #1 destroyed the expired medication. |
12/07/2021
| Implemented |
| 6500.135(a) | Individual #1 was administered Polyeye drops on 10/5/21 and 10/20/21. The individual's record did not include a physician's order for administration of this medication.
Individual #1 was administered Polymyxin B-tmp eye drops on 9/7/21 and 8/17/21. The record did not include a physician's order for administration of this medication.
According to Individual #1's medication administration records (mars) the individual is prescribed Clonazepam .5mg to be administered by mouth once as needed for seizures for up to one dose. The physician's order did not include current information for when to administer the medication or the parameters for when to administer the medication based on certain circumstances of the individual's seizures. According to the family during the 11/9/21 visit, the medication is to be used at some point when Individual #1 experiences cluster seizures. This physician's order could not be produced.
As described throughout this report, Polymxin B sulfate & Trimethoprim Ophthalmic Solution (or a version of this medication's name recorded on Individual #1's mars; Polyeye drops, Polymyxin B-tmp and Polymyrin eyes) was administered to Individual #1 multiple times after February 2021. During the 11/9/21 onsite inspection, the medication label stated the medication expired in February 2021. Family member #1 confirmed during the inspection that the expired medication was the only Polymxin eye drop medication at the home over the previous year and the only Polymxin eye drop administered to the individual. Additionally, the medication label found at the home, not attached to the Polymxin medication, stated to dispose of the medication by 12/1/2020, and the instructions were to administer the medication 1 drop into the left eye 4 times a day for 7 days. The medication instructions on the medication box stated to administer one drop in affected eye(s) every 3 hours see package insert. A package insert was not located at the home. The medication bottle itself did not include administration instructions. The individual's record did not include written instructions from the prescriber for administration of this medication. | A prescription medication shall be prescribed in writing by an authorized prescriber. | This regulation is important to ensure that Individual #1 is being administered medication safely and correctly.
Family Member #1 received verbal instructions or limited written instructions about the administration of Polyeye drops and Clonazepam. A written order or clarification was never documented.
Family Member #1 did not seek written prescriptions from the physician when verbal instructions were given. The physician provided an updated prescription for Polyeye drop and will document details on when and how clonazepam should be administered. |
12/06/2021
| Implemented |
| 6500.135(b) | According to Individual #1's medication administration records (mars) the individual is prescribed Clonazepam .5mg to be administered by mouth once as needed for seizures for up to one dose. The physician's order did not include current information for when to administer the medication or the parameters for when to administer the medication based on certain circumstances of the individual's seizures. According to the family during the 11/9/21 visit, the medication is to be used at some point when Individual #1 experiences cluster seizures. This physician's order could not be produced.
As described throughout this report, Polymxin B sulfate & Trimethoprim Ophthalmic Solution (or a version of this medication's name recorded on Individual #1's mars; Polyeye drops, Polymyxin B-tmp and Polymyrin eyes) was administered to Individual #1 multiple times after February 2021. During the 11/9/21 onsite inspection, the medication label stated the medication expired in February 2021. Family member #1 confirmed during the inspection that the expired medication was the only Polymxin eye drop medication at the home over the previous year and the only Polymxin eye drop administered to the individual. Additionally, the medication label found at the home, not attached to the Polymxin medication, stated to dispose of the medication by 12/1/2020 and the instructions were to administer the medication 1 drop into the left eye 4 times a day for 7 days. The medication instructions on the medication box stated to administer one drop in affected eye(s) every 3 hours see package insert. A package insert was not located at the home. The medication bottle itself did not include administration instructions. There were no records maintained for the current order of the medication. | A prescription order shall be kept current. | This regulation is important to ensure that Individual #1 is being administered medication safely and correctly.
Family Member #1 received verbal instructions or limited written instructions about the administration of Polyeye drops and Clonazepam. A written order or clarification was never documented.
Family Member #1 did not seek written prescriptions from the physician when verbal instructions were given or when a prescription expired.
The physician provided an updated prescription for Polyeye drop and will document details on when and how clonazepam should be administered. |
12/06/2021
| Implemented |
| 6500.135(c) | Individual #1 is prescribed Clonazepam .5mg to be administered by mouth once as needed for seizures. Staff administered this medication to Individual #1 on 7/9/21. According to the individual's seizure record, the individual did not experience a seizure on 7/9/21 yet the home administered the medication.
Medication described in 6500.124, 135(a), and 135(b) were not administered as ordered. | A prescription medication shall be administered as prescribed. | This regulation is important to ensure that Individual #1 is being administered medication safely and correctly.
Family Member #1 administered Clonazepam without documentation to back up why it was administered.
Family Member #1 did not keep a seizure log for July 2021.
The physician will document details on when and how clonazepam should be administered. Family Member #1 will document all seizure activity on a seizure log. |
12/06/2021
| Implemented |
| 6500.136(a)(4) | Family member #1 documented they administered Polymyrin eyes to Individual #1 on 2/11/21. The full name of the medication was not recorded on the individual's medication administration record. During the 11/9/21 visit to the home, Family member #1 confirmed the only medication they had in the home to administer to Individual #1 for their eyes was Polymxin B Sulfate & Trimethoprim Ophthalmic Solution 10ml.
Additionally, Family member #1 administered this medication to Individual #1 throughout the year (November 2020-November 2021) and never recorded the full name of the medication for any of the administrations captured throughout this violation report. Examples of medication names documented was Polyeye drops, Polymyxin B-tmp and Polymyrin eyes. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | This regulation is important to ensure that Individual #1 is being administered medication safely and correctly.
¿Poly B Sulfate & Trimethoprim Opthalmic Solution 10ml¿ was recorded on the MAR under abbreviated names.
The proper name of the medication is long, so Family Member #1 chose to abbreviate it.
Family Member #1 completed an updated medication administration training that goes over how to correctly fill out a MAR. |
12/07/2021
| Implemented |
| 6500.136(a)(5) | Individual #1's October 5th and 30th, 2021 medication administration records (mars) stated that Polyeye drops were administered. Additionally, Polymyxin B-tmp eye drops were documented as administered on 9/7/21, 8/17/21, and 4/25/21. Polymyrin eyes was administered on 2/11/21. However, the strength of the medications were not recorded on the mar. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | This regulation is important to ensure that Individual #1 is being administered medication safely and correctly.
Polyeye drops were recorded on the MAR without the strength of the medication
Family Member #1 did not record the strength of the medication on the MAR.
Family Member #1 completed an updated medication administration training that goes over how to correctly fill out a MAR. |
12/07/2021
| Implemented |
| 6500.136(a)(6) | Family member #1 documented they administered Polymyrin eyes to Individual #1 on 2/11/21. The dosage form was not recorded on the individual's medication administration records. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | This regulation is important to ensure that Individual #1 is being administered medication safely and correctly.
Polyeye drops were recorded on the MAR without the dosage form of the medication
Family Member #1 did not record the dosage form of the medication on the MAR.
Family Member #1 completed an updated medication administration training that goes over how to correctly fill out a MAR. |
12/07/2021
| Implemented |
| 6500.136(a)(7) | Individual #1's October 5th and 30th, 2021 medication administration records (mars) stated that Polyeye drops were administered. Additionally, Polymyxin B-tmp eye drops were documented as administered on 9/7/21, 8/17/21, and 4/25/21. Polymyrin eyes was administered on 2/11/21 However, the dose of the medications administered were not recorded on the mar. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | This regulation is important to ensure that Individual #1 is being administered medication safely and correctly.
Polyeye drops were recorded on the MAR without the dose of the medication
Family Member #1 did not record the dose of the medication on the MAR.
Family Member #1 completed an updated medication administration training that goes over how to correctly fill out a MAR. |
12/07/2021
| Implemented |
| 6500.136(a)(8) | Family member #1 documented they administered Polymyrin eyes to Individual #1 on 2/11/21 and PolymyxinB on 4/25/21. The route the medications were administered wasn't recorded on the individual's medication administration records. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | This regulation is important to ensure that Individual #1 is being administered medication safely and correctly.
Polyeye drops were recorded on the MAR without the route of the medication
Family Member #1 did not record the route of the medication on the MAR.
Family Member #1 completed an updated medication administration training that goes over how to correctly fill out a MAR. |
12/07/2021
| Implemented |
| 6500.136(a)(9) | Individual #1's October 5th and 30th, 2021 medication administration records (mars) stated that Polyeye drops were administered. Additionally, Polymyxin B-tmp eye drops were documented as administered on 9/7/21, 8/17/21, and 4/25/21. Family member #1 documented they administered Polymyrin eyes to Individual #1 on 2/11/21. However, the frequency of administration of the medications were not recorded on the mar. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | This regulation is important to ensure that Individual #1 is being administered medication safely and correctly.
Polyeye drops were recorded on the MAR without the frequency of the medication
Family Member #1 did not record the frequency of the medication on the MAR.
Family Member #1 completed an updated medication administration training that goes over how to correctly fill out a MAR. |
12/07/2021
| Implemented |
| 6500.136(a)(10) | Individual #1's October 5th and 30th, 2021 medication administration records (mars) stated that Polyeye drops were administered. Additionally, Polymyxin B-tmp eye drops were documented as administered on 9/7/21, 8/17/21, and 4/25/21. Family member #1 documented they administered Polymyrin eyes to Individual #1 on 2/11/21. However, the administration times of the medications were not recorded on the mar. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | This regulation is important to ensure that Individual #1 is being administered medication safely and correctly.
Polyeye drops were recorded on the MAR without the administration time of the medication
Family Member #1 did not record the administration time of the medication on the MAR.
Family Member #1 completed an updated medication administration training that goes over how to correctly fill out a MAR.
Life Sharing Specialist will review each month¿s MAR to ensure they are filled out correctly. Corrections will be made as appropriate. |
12/07/2021
| Implemented |
| 6500.136(a)(11) | Individual #1's medication administration records (mar) did not include the diagnosis or reason for prescribing their Carbamazepine, Levetiracetam, Glycopyrrolate, Pediasure, Polyeye drops, and Polymyxin B-tmp eye drops. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | This regulation is important to ensure that Individual #1 is being administered medication safely and correctly.
Medications were recorded on the MAR without the diagnosis/purpose of the medication
Family Member #1 did not record the diagnosis/purpose of the medication on the MAR.
Family Member #1 completed an updated medication administration training that goes over how to correctly fill out a MAR. |
12/07/2021
| Implemented |
| 6500.136(a)(12) | Individual #1's October 5th and 30th, 2021 medication administration records (mars) stated that Polyeye drops were administered. Additionally, Polymyxin B-tmp eye drops were documented as administered on 9/7/21, 8/17/21, and 4/25/21. Clonazepam was administered on 7/9/21, 5/16/21, 5/5/21, 2/5/21, and 4/14/21 for a one-time dose. Family member #1 documented they administered Polymyrin eyes to Individual #1 on 2/11/21. However, the time of administration of the medications were not recorded on the mar. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration. | This regulation is important to ensure that Individual #1 is being administered medication safely and correctly.
Medications were recorded on the MAR without the date and time of administration of the medication
Family Member #1 did not record the date and time of administration of the medication on the MAR.
Family Member #1 completed an updated medication administration training that goes over how to correctly fill out a MAR. |
12/07/2021
| Implemented |
| 6500.136(a)(14) | Individual #1's October 5th and 30th, 2021 medication administration records (mars) stated that Polyeye drops were administered. Additionally, Polymyxin B-tmp eye drops were documented as administered on 9/7/21, 8/17/21, and 4/25/21. Family member #1 documented they administered Polymyrin eyes to Individual #1 on 2/11/21. However, the duration of the treatment of the medications were not recorded on the mar. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Duration of treatment, if applicable. | This regulation is important to ensure that Individual #1 is being administered medication safely and correctly.
Polyeye drops were recorded on the MAR without the duration of treatment for the medication
Family Member #1 did not record the duration of treatment for the medication on the MAR.
Family Member #1 completed an updated medication administration training that goes over how to correctly fill out a MAR. |
12/07/2021
| Implemented |
| 6500.136(a)(15) | Individual #1's October 5th and 30th, 2021 medication administration records (mars) stated that Polyeye drops were administered. Additionally, Polymyxin B-tmp eye drops were documented as administered on 9/7/21, 8/17/21, 4/25/21. Family member #1 documented they administered Polymyrin eyes to Individual #1 on 2/11/21. However, the special precautions of the medications were not recorded on the mar. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Special precautions, if applicable. | This regulation is important to ensure that Individual #1 is being administered medication safely and correctly.
Polyeye drops were recorded on the MAR without special precautions for the medication
Family Member #1 did not record the special precautions for the medication on the MAR.
Family Member #1 completed an updated medication administration training that goes over how to correctly fill out a MAR. |
12/07/2021
| Implemented |
| 6500.136(a)(16) | Individual #1's October 5th and 30th, 2021 medication administration records (mars) stated that Polyeye drops were administered. Additionally, Polymyxin B-tmp eye drops were documented as administered on 9/7/21, 8/17/21, 4/25/21. Family member #1 documented they administered Polymyrin eyes to Individual #1 on 2/11/21. However, the side effects of the medication were not recorded on the mar. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Side effects of the medication, if applicable. | This regulation is important to ensure that Individual #1 is being administered medication safely and correctly.
Polyeye drops were recorded on the MAR without side effects for the medication
Family Member #1 did not record the side effects for the medication on the MAR.
Family Member #1 completed an updated medication administration training that goes over how to correctly fill out a MAR. |
12/07/2021
| Implemented |
| 6500.137(b) | Medication errors referenced within this entire report and captured in 6500.135(c) of this report, were not documented, reported to the individual's physicians or the Department, and follow-up action taken and the prescriber's response was not kept in the individual's record. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | This regulation is important to ensure that Individual #1 is being administered medication safely and correctly.
Medication errors were not reported to the department and physician correspondence was not recorded.
Family Member #1 did not report medication errors. The agency does not receive MARS until the month is complete and medication errors were not caught at this time.
Family Member #1 completed an updated medication administration training that goes over all types of medication errors and what to do when they occur. |
12/07/2021
| Implemented |
| 6500.151(d) | The program specialist did not sign and date Individual #1's 2/8/2021 assessment. | The life sharing specialist shall sign and date the assessment. | This regulation is important to ensure that everyone involved in Individual #1¿s care has read the assessment.
The Life Sharing Specialist uploaded an unsigned copy of Individual #1¿s 2/8/2021 assessment.
The Life Sharing Specialist uploaded a copy of the assessment directly from her computer instead of scanning the signed copy that is kept on file.
Upload the signed and dated copy of the assessment. |
12/08/2021
| Implemented |
| 6500.151(f) | There are no records maintained that Individual #1's 2/8/2021 assessment was sent to any team members. The agency produced a letter head created on 2/12/2021 stating the annual assessment is attached. However, the letter states the assessment was distributed to all team members on 2/15/2019. The individual's annual individual planning meeting was held 3/15/21 virtually. | The life sharing specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | This regulation is important to ensure that everyone involved in Individual #1¿s is informed about their care.
The Life Sharing Specialist sent all information to team member on 2/15/2021 for an assessment meeting 3/15/2021
The assessment was sent 1 month prior to the meeting.
Continue to maintain compliance by sending assessments thirty days prior to meetings. |
12/10/2021
| Implemented |
| 6500.155(5) | According to Individual #1's mars over the previous year, November 2020 to November 2021, they were administered Clonazepam .5mg for seizures as needed. The agency, Compass Community Connections, was not able to produce the physician's directive/order for the parameters that need to be met in order to administer the medication as needed for seizures. Per Family member #1, Clonazepam is to be administered to Individual #1 when they are experiencing cluster seizures. Individual #1's seizure protocol included in their individual support plan (isp) does not include the use of Clonazepam, when to administer the medication, or information about their cluster seizures. The individual's seizure protocol does not include the signs and symptoms staff and family members are to watch for prior to, during and after a seizure, how staff and family are to assist Individual #1 during a seizure to maintain the individual's safety, how to assist the individual after a seizure, the types of seizures the individual experiences or any information from the individual's neurologist. The seizure protocol states that 911 must be contacted if the seizure last more than 5 minutes or multiple seizure occur in a row without return to baseline. The protocol does not include information about the length of time that's acceptable after the seizure(s), for the individual to return to baseline to maintain their safety.
Additionally, on 3/25/21 Individual #1's neurologist instructed the home to have a "helmet on hand" due to the individual's seizures. The individual's individual plan and seizure protocol do not include the neurologist's order for a helmet, instructions on when and how to use the helmet, or any information regarding the use of helmet for Individual #1's seizures.
Individual #1's individual plan states the individual can eat quarter-sized portions of food but that they should also only eat nickel-sized portions of food due to choking risks. The individual's plan does not define the specific size of food they should eat to prevent choking or aspiration. | The individual plan, including revisions, must include the following: Risks to the individual's health, safety or well-being, behaviors likely to result in immediate physical harm to the individual or others and risk mitigation strategies, if applicable. | This regulation is important to ensure that everyone involved in Individual #1¿s is reading the same (correct) information.
The Life Sharing Specialist has some inconsistencies in Individual #1¿s ISP and assessment.
The Life Sharing Specialist did not match the ISP, assessment, and health risk protocol.
Gather clarification from the physician on usage of the Clonazepam, instructions for the helmet, and clarification on dietary instructions. |
12/08/2021
| Implemented |