| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The self assessment for the home was completed on 1/8/2020. The agency's certificate of compliance expires on 3/10/2020. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, 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.
| The Assistant Directors will be trained on the self-assessment licensing tool and timeframe of completion. This training was completed on 3-3-20. The self-assessments licensing tool will be completed 3 to 6 months prior to the last annual inspection by ODP.[Immediately, the CEO or designee shall develop a tracking and notification system to ensure the self-assessment for each home will be complete with 3 to 6 months prior to the expiration date of the agency's certificate of compliance. Within 30 days, the CEO or designee shall educate assistance directors of the procedures for accurate and timely completed of the self assessments. Documentation of the trainings shall be kept. Prior to 3 months of the expiration of the agency's certificate of compliance, a designated management staff person shall audit the self assessments to ensure accurate, full and timely completion of all self assessments. Documentation of the audits shall be kept. (DPOC by AES,HSLS on 3/11/20)] |
03/03/2020
| Implemented |
| 6400.166(a)(4) | Advair Disku AER 500/50 prescribed to Individual #1 was not included on Individual #1's February 2020 medication administration record. Individual #1 was administered the medication at 8:00AM from February 1 to February 11, 2020. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | The Residential Managers will review the MAR¿s at the beginning of each month when bulk medications come in to ensure all medications are properly labeled on the Med Logs. There will be a signature sheet that will be filled out by the Residential Managers and reviewed by the Residential Program Specialist monthly. The 9th avenue team will be retrained on documenting medication on the MAR¿s. The 9th avenue team will be trained by 4-1-20. [Immediately and continuing at least monthly, a designated staff person shall audit all individuals' mediations, current medication administration records and doctors' order to ensure all individuals are administered medications as prescribed and documented as required. Documentation of the audits shall be kept. Staff retraining shall be completed as needed based on audits. (DPOC by AES, HSLS on 3/11/20)] |
04/01/2020
| Implemented |
| 6400.166(b) | Advair Disku AER 500/50 prescribed to Individual #1 was not initialed as administered at 8:00AM from February 1 to February 11, 2020. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The Residential Managers will review the MAR¿s at the beginning of each month when bulk medications come in to ensure all medications are properly labeled on the Med Logs. There will be a signature sheet that will be filled out by the Residential Managers and reviewed by the Residential Program Specialist monthly. The 9th avenue team will be retrained on documenting medication on the MAR¿s. The 9th avenue team will be trained by 4-1-20.[Immediately and continuing at least monthly, a designated staff person shall audit all individuals' mediations, current medication administration records and doctors' order to ensure all individuals are administered medications as prescribed and documented as required. Documentation of the audits shall be kept. Staff retraining shall be completed as needed based on audits. (DPOC by AES, HSLS on 3/11/20)] |
04/01/2020
| Implemented |