Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.43(b)(3) | On 5/18/2023 the chief executive officer did not maintain safety and protection of the individuals. Individual #1 has a G-Tube and their medication administration record documented the route of administration as by mouth for multiple medications and the individual support plan, last updated 9/27/2022, states Individual #1 does not take anything by mouth. Individual #2 was prescribed Polyethylene Glycol Powder to be administered on days where she did not have a bowel movement. individual #2's bowel movement documentation recorded she did not have a bowel movement 5/01/2023 thru 5/05/2023, 5/07/2023 thru 5/12/2023, and 5/14/2023 thru 5/16/2023 and the medication was not administered. On 5/18/2023 there were multiple medications unlocked and accessible to the individuals and expired medications in the home. Individual #2 is prescribed Nayzilam Spray 5mg, use 1 dose intranasally as needed for seizures lasting greater than 5 minutes, which was not present in the home on 5/18/2023. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. | On 5/18/23 the Director of Community Health/RN sent orders to the PCP for Individual #1 to discontinue all PO orders and replace with proper route (peg tube). On 5/19/23 the Director of Community Health and Residential Director (CEO) audited all medications and medication administration records for all 3 individuals. All PRN medications no longer needed were discontinued by the PCP and removed from the MAR. All PRN medications listed on the MAR were reordered and delivered by the pharmacy. All medications and creams were in locked cabinet. The Director of Community Health/RN sent orders to the PCP for Individual #2. On On 5/26/23 the Adult Services Trainer and Program Manager completed another audit for all 3 individuals. Final orders were submitted for Individual #3 to PCP for pharmacy. On June 6, 2023 Individual #1 had appointment with his PCP and a follow-up on June 12, 2023. On June 7, 2023, the Residential Director (CEO) and Adult Services management participated in a re-training on the medication administration regulations which included the 5 rights, PRN medications, storing medications, disposing of expired and discontinued medications, and ensuring prescribed medications are in the home. All Direct Support Professionals will be retrained on the medication administration regulations, including storing of medications by July 7, 2023. The Home Coordinators will continue to do weekly audits and Program Managers, monthly audits. The Residential Director will conduct sampling audits on a quarterly basis. |
07/07/2023
| Not Implemented |
6400.163(d) | On 5/18/2023 the following medications were observed unlocked and located in Individual #1's bedroom in the top dresser drawer: Desitin Cream 0.13%, Aloe Vesta Ointment Protect, Vitamin A&D Ointment, Petroleum Jelly Gel, and Vaseline Lip Therapy. The individual is unable to self-administer medications. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | On 5/18/23, the Residential Director, Director of Community Health, and Adult Services Trainer removed the medications from the top dresser drawer in Individual #1's bedroom and placed them in a locked cabinet. The Home Coordinator received individual feedback re: ODP Medication Administration Training and protocol, including proper storage of all medications. |
07/07/2023
| Not Implemented |
6400.163(h) | On 9/06/2022 Individual #1 was prescribed Diphenhydramine 50mg capsule, take 1 capsule by mouth every 8 hours as needed for 20 days. On 5/18/2023 the medication was present in Individual #1's medication storage. On 5/18/2023 the following expired medications prescribed to individual #1 were observed in the home: Ondansetron 4mg ODT tablet expired 3/27/2023, Antacid/Anti-Gas expired 3/27/2023, Siltussin SA 100/5ml Syrup expired 4/21/2023, and Duoderm CGF Extra Thin expired 3/27/2023. On 5/18/2023 the following expired medications prescribed to individual #2 were observed in the home: Chloraseptic 6-10mg Lozenge expired 2/27/2023 and Duoderm CGF Extra Thin expired 3/27/2023. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | On 5/18/23 the Director of Community Health and Residential Director removed all expired medications from the home and followed PathWays policy for disposing of expired and discontinued medications. |
07/07/2023
| Not Implemented |
6400.165(b) | On 5/18/2023 the following pro re nata medications prescribed to Individual #1 were not in the home: Albuterol Nebulizer 0.083%, Triaminicol, Loperamide 2mg Capsule, Metamucil 0.52gm capsule, Pepto Bismol Sus 262/15ml, and SM Stomach Sus 525/30ml. On 5/18/2023 the following pro re nata medications prescribed to Individual #2 were not in the home: Acetaminophen 325mg tablet, Nayzilam 5mg spray, Pseudoephedrine 30mg tablet, and Senna-Plus 8.6-50mg tablet. | A prescription order shall be kept current. | On 5/19/23, the Director of Community Health and Residential Director conducted an audit of the Medication Administration Record and medications in the home. An order was sent to the pharmacy to discontinue PRN medications that were no longer needed. The Director of Community Health reordered current PRN medications that were not in the home. |
07/07/2023
| Not Implemented |
6400.166(a)(4) | On 5/18/2023 Individual #1's May 2023 medication administration record did not include the following medication names: Ocusoft Lid Pad Original and Hydrocortisone 1% cream. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | On 5/18/23, the Director of Community Health, Adult Services Trainer and Program Manager verified the Ocusoft Lid Pad had been administered and recorded as required in the electronic medication administration record (QuickMAR) by reviewing the Treatment Administration Record (TAR) report. The staff discussed this with the ODP Inspectors who indicated the printed version (provided in the morning) did not include this information. When the MAR was printed, the section which includes the TAR did not print, although it was present and administered as required. |
05/18/2023
| Not Implemented |
6400.166(a)(5) | On 5/18/2023 Individual #1's May 2023 medication administration record did not include the strength of the medication for the following: Ocusoft Lid Pad Original and Hydrocortisone 1% Aloe cream. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | On 5/18/23, the Director of Community Health, Adult Services Trainer and Program Manager verified the Ocusoft Lid Pad had been administered and recorded as required in the electronic medication administration record (QuickMAR) by reviewing the Treatment Administration Record (TAR) report. The staff discussed this with the ODP Inspectors who indicated the printed version (provided in the morning) did not include this information. When the MAR was printed, the section which includes the TAR did not print, although it was present and administered as required. |
05/18/2023
| Not Implemented |
6400.166(a)(6) | On 5/18/2023 Individual #1's May 2023 medication administration record did not include the dosage form for the following medications: Ocusoft Lid Pad Original and Hydrocortisone 1% Aloe cream. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | On 5/18/23, the Director of Community Health, Adult Services Trainer and Program Manager verified the Ocusoft Lid Pad had been administered and recorded as required in the electronic medication administration record (QuickMAR) by reviewing the Treatment Administration Record (TAR) report. The staff discussed this with the ODP Inspectors who indicated the printed version (provided in the morning) did not include this information. When the MAR was printed, the section which includes the TAR did not print, although it was present and administered as required. |
05/18/2023
| Not Implemented |
6400.166(a)(7) | On 5/18/2023 Individual #1's May 2023 medication administration record did not include the dose for the following medications: Ocusoft Lid Pad Original, Hydrocortisone 1% Aloe cream, Antacid/Anti-Gas, Antidiarrhea 2mg tablet, Bacitracin Ointment 500/gm, Epinephrine 0.3mg injection, Triaminicol, Metamucil 0.52gm capsule, Pepto Bismol Sus 262/15ml, Pseudoephedrine 30mg tablet, and SM Stomach Sus 525/30ml. Individual #2's May 2023 medication administration record did not include dose for the following medications: Acetaminophen 325mg tablet, Antacid/Anti-gas, Chloraseptic 6-10mg Lozenge, Citrucel Powder SF Orange, Hydrocortisone Cream 1%, Ibuprofen 200mg tablet, Metamucil SF Orange, Pepto Bismol Sus 262/15ml, Pseudoephedrine 30mg tablet, QC Pink Bismuth 236ml, Senna-Plus 8.6-50mg tablet, and Siltussin DM LIQ DAS. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | On 5/19/23, the Residential Director and Director of Community Health reviewed the MAR and medications. On 5/19/23, The Director of Community Health contacted the doctor's office to send updated orders to the pharmacy. The MAR has been updated to include the doses. |
07/07/2023
| Not Implemented |
6400.166(a)(8) | Individual #1's individual support plan, last updated 9/27/2022 states he does not take anything by mouth and staff place meds in feeding tube. On 5/18/2023 Individual #1's May 2023 medication administration record documented the following medications to be given by mouth as the route of administration: Fleqsuvy Sus 25mg/ml, Fluoxetine Sol 20mg/5ml, Polyethylene Glycol Powder 3350 NF, Risperidone Sol 1mg/ml, and Loperamide 2mg capsule. Individual #1's May 2023 medication administration lists Doxazosin 4mg tablet, take 1 tablet via peg tube every day for high blood pressure, and does not give specifics on how the medication is prepared for that route of administration. Individual #1's May 2023 medication administration record states the individual is prescribed Ibuprofen Sus 100/5ml with instructions to give 20ml with food or milk three times a day as needed. Individual #1 is prescribed Petroleum Jelly Gel, Vitamin A&D Ointment, Aloe Vesta Ointment, and Lidocaine Cream 4% and the route of administration is documented as "affected area" on Individual #1's May 2023 medication administration record and does not provide detail on where the affected areas are. Individual #1's May 2023 medication administration record did not include the route of administration for the following medications: Ocusoft Lid Pad Original, Antacid/Anti-Gas, Antidiarrhea 2mg tablet, Bacitracin Ointment 500/gm, Epinephrine 0.3mg injection, Triaminicol, Metamucil 0.52gm capsule, Pepto Bismol Sus 262/15ml, Pseudoephedrine 30mg tablet, and SM Stomach Sus 525/30ml. Individual #2's May 2023 medication administration record did not include the route of administration for the following medications: Acetaminophen 325mg tablet, Antacid/Anti-gas, Chloraseptic 6-10mg Lozenge, Citrucel Powder SF Orange, Hydrocortisone Cream 1%, Ibuprofen 200mg tablet, Metamucil SF Orange, Pepto Bismol Sus 262/15ml, Pseudoephedrine 30mg tablet, QC Pink Bismuth 236ml, Senna-Plus 8.6-50mg tablet, and Siltussin DM LIQ DAS. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | On 5/18/23, the Director of Community Health contacted the prescribing doctors and pharmacy to update the orders for the route to be via peg tube rather than by mouth. On 5/19/23, new labels were provided for most medications and the MARs for those medications were updated with the appropriate route. While at the PCP on 6/5/23, the Home Coordinator followed up with the PCP for the additional updated orders to be sent and their office said they had to wait because they were sending him to the ER due to his pulse ox being low and a fever. They will not send the orders over until his follow up appointment with the PCP on 6/12/23. |
07/07/2023
| Not Implemented |
6400.166(a)(9) | On 5/18/2023 Individual #1's May 2023 medication administration record did not include the frequency of administration for the following medications: Ocusoft Lid Pad Original, Hydrocortisone 1% Aloe cream, Antacid/Anti-Gas, Antidiarrhea 2mg tablet, Bacitracin Ointment 500/gm, Epinephrine 0.3mg injection, Triaminicol, Metamucil 0.52gm capsule, Pepto Bismol Sus 262/15ml, Pseudoephedrine 30mg tablet, and SM Stomach Sus 525/30ml. Individual #2's May 2023 medication administration record did not include the frequency of administration for the following medications: Acetaminophen 325mg tablet, Antacid/Anti-gas, Chloraseptic 6-10mg Lozenge, Citrucel Powder SF Orange, Hydrocortisone Cream 1%, Ibuprofen 200mg tablet, Metamucil SF Orange, Pepto Bismol Sus 262/15ml, Pseudoephedrine 30mg tablet, QC Pink Bismuth 236ml, Senna-Plus 8.6-50mg tablet, and Siltussin DM LIQ DAS. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | On 5/19/23, the Director of Community Health and Residential Director reviewed the MAR and medications. On 5/19/23, The Director of Community Health contacted the doctor's office to have updated orders sent to the pharmacy. The MAR has been updated to include the frequency of administration. |
07/07/2023
| Not Implemented |
6400.166(a)(10) | On 5/18/2023 Individual #1's May 2023 medication administration record did not include administration times for the following medication: Ocusoft Lid Pad Original | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | PathWays disagrees with this violation: On 5/18/23, the Director of Community Health, Adult Services Trainer and Program Manager verified the Ocusoft Lid Pad had been administered and recorded as required in the electronic medication administration record (QuickMAR) by reviewing the Treatment Administration Record (TAR) report. The staff discussed this with the ODP Inspectors who indicated the printed version (provided in the morning) did not include this information. When the MAR was printed, the section which includes the TAR did not print, although it was present and administered as required. |
05/18/2023
| Not Implemented |
6400.166(a)(11) | On 5/18/2023 Individual #1's May 2023 medication administration record did not include the diagnosis or purpose for the following medications: Ocusoft Lid Pad Original, Hydrocortisone 1% Aloe cream, Petroleum Jelly Gel, Aloe Vesta Ointment Protect, and Vaseline Lip Therapy. Individual #3's May 2023 medication administration record did not include diagnosis or purpose for the following medications: Chlorhex Glu Sol 0.12% and Ocusoft Lid Pad Original. | 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. | On 5/19/23, the Residential Director and Director of Community Health Reviewed the medication and MARs in the home. These treatments and the diagnosis/purpose were added to the MAR on 5/24/23. |
05/24/2023
| Not Implemented |
6400.166(a)(12) | On 5/18/2023 Individual #1's May 2023 medication administration record did not include the date and time of medication administrations for the Ocusoft Lid Pad Original, rub each eye with side-to-side strokes, then rinse with water every day for eye care. | 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. | On 5/18/23, the Director of Community Health, Adult Services Trainer and Program Manager verified the Ocusoft Lid Pad had been administered and recorded as required in the electronic medication administration record (QuickMAR) by reviewing the Treatment Administration Record (TAR) report. The staff discussed this with the ODP Inspectors who indicated the printed version (provided in the morning) did not include this information. When the MAR was printed, the section which includes the TAR did not print, although it was present and administered as required. |
05/18/2023
| Not Implemented |
6400.166(a)(13) | On 5/18/2023 Individual #1's May 2023 medication administration record did not include name and initials of the person who administered the Ocusoft Lid Pad Original 5/01/2023 through 5/18/2023. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | On 5/18/23, the Director of Community Health, Adult Services Trainer and Program Manager verified the Ocusoft Lid Pad had been administered and recorded as required in the electronic medication administration record (QuickMAR) by reviewing the Treatment Administration Record (TAR) report. The staff discussed this with the ODP Inspectors who indicated the printed version (provided in the morning) did not include this information. When the MAR was printed, the section which includes the TAR did not print, although it was present and administered as required. |
05/18/2023
| Not Implemented |
6400.167(a)(1) | Individual #2 is prescribed Polyethylene Glycol Powder 3350 NF, mix ½ capful (8.5gm) with 4-8 oz of fluid and give at bedtime as needed if no bowel movement. individual #2's bowel movement documentation records no bowel movements from 5/01/2023 thru 5/05/2023, 5/07/2023 thru 5/12/2023, and 5/14/2023 thru 5/16/2023 and the medication was not administered at all in May 2023. | Medication errors include the following: Failure to administer a medication. | On 5/19/23, the Community Health Director requested a medication refill for Polyethylene Glycol Powder 3350 NF, mix ½ capful (8.5gm) with 4-8 oz of fluid and reviewed the bowel movement chart to identify if it needed administered on 5/19/23. Management validated that all staff had their ODP medication administration training. EIM report submission overlooked; submitted 6/10/23 (9229899). |
07/07/2023
| Not Implemented |
6400.182(c) | Individual #1's individual support plan, last updated 9/27/2022, states the route of administration by mouth for the following medications: Propranolol 60mg tablet, Fiber Lax 625mg tablet, Fluoxetine HCL 40mg capsule, Baclofen 10mg tablet, Lorazepam 0.5mg tablet, and Finasteride 5mg tablet. The plan also states the individual does not take anything by mouth and staff place meds in feeding tube. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | After the 9/27/22 ISP, several contacts with Support Coordinator(s) by the Clinical Specialist and Director of Community Health regarding Individual #1's changing needs/ISP updates occurred, in addition to a team meeting held in early March. On 6/1/23, the Director of Community Health emailed the Supports Coordinator for additional follow-up. After receiving an out of office message, the Director of Community Health emailed the SC Supervisor who said to follow up with the SC. The Director of Community Health is awaiting a reply from the SC. |
07/15/2023
| Implemented |