| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | 77 (b) The first aid kit did not contain a thermometer. (Thermometer was located during inspection) | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | Based on the licensing review on November 8-9, 2023, the BHID Director reviewed the list of required first aid items with the Program Supervisor. All required items were located on site and placed inside of the first aid kit. |
11/09/2023
| Implemented |
| 6400.141(a) | 141 (a) The physical examination for individual #1 was completed late, previous scheduled exam was completed 08/03/2022 and current exam was not completed until 09/15/2023. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Based on the licensing review of November 8-9, 2023, BHID Program Supervisor and Director reviewed the regulations for annual physicals and the importance of completing this requirement annually. |
11/09/2023
| Implemented |
| 6400.141(c)(13) | 141 (c)(13) Individual #1's allergies were omitted on the physical form dated 09/15.2023. | The physical examination shall include: Allergies or contraindicated medications. | Based on the licensing review of November 8-9, 2023, the Program Director verified on 11/9/23 that the allergy information was on the completed 2023 physical form. The physician completing the physical documented `none¿ in section: Medication allergies, sensitivities, or contra-indicated medications. |
11/09/2023
| Implemented |
| 6400.141(c)(14) | 141(c)(14) Information pertinent to diagnosis in case of emergency was omitted on the physical exam dated 09/15/23. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Based on the licensing review of November 8-9, 2023, the Program Director and Supervisor located physician¿s notes from the annual exam indicating the resident¿s diagnosis. The Program Supervisor also implemented an alternate physical form that includes specific details on diagnoses. Program supervisor removed form in question from site 11/10/23 and provided updated physical form on site 11/10/23. |
11/09/2023
| Implemented |
| 6400.144 | There is an order listed to take individual #1's blood pressure. The order does not indicate when the blood pressure reading is to occur. The agency stated it was a verbal order and that they are completing the test on Monday and Wednesday in the a.m., however, on the form the agency is utilizing the test is being completed at times in the evening.
The agency has an order for a blood pressure cuff and monitor but no order for when to use it or how to use it. There is no protocol in place as to what staff are to do if the blood pressure reading is high or low. The staff has no direction as to what should be done in the event that this occurs. | 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.
| Based on the licensing review on November 8-9, 2023, the BHID Director reviewed and retrained the Program Supervisor and Site Staff on supporting documentation needed for monitoring an individual¿s blood pressure. The Program Director located documentation of the physician¿s order for monitoring the individual¿s blood pressure on 11/9/23 |
11/09/2023
| Implemented |
| 6400.166(a)(13) | 166 (a)(13) The medication was not signed as administered on 11/09/2023 by the staff that administered the medication. | 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. | Based on the licensing review of November 8-9, 2023, the BH Director informed the staff responsible of the medication error and had them sign the MAR on 11/9/23. The staff responsible for the medication error received medication points/discipline on 11/17/23. |
11/17/2023
| Implemented |