| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.70 | The home does not have a telephone that is easily accessible to individuals and staff persons. The telephone is located in a locked office area where cleaning products and medications are stored. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| As noted in the individuals BSP, which has been attached for your review, the individual that resides in that one person group home will throw objects in his reach. Therefore we have elected to keep the phone in the staff office when the individual and staff are not in the residence for charging purposes. Leaving the base in the common area would give the individual the opportunity to pick it up and throw it. When the individual is home, the phone is made available to him should he receive a call or want to make one. [The home will apply for a waiver or the telephone will be kept unlocked at all times due to the requirement to have a phone with an outside line easily accessible to individuals and staff persons. (CHG 12/5/13)] |
11/27/2013
| Implemented |
| 6400.71 | The telephone number of the nearest hospital was not on or by the telephone in the office area of the home. | 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 with an outside line.
| Habilitation Specialist has placed new labels on all telephones in the house that contain the following information: The number to the nearest hospital, poison control and 911 for police, fire and/or ambulance. In addition, signs with all this information will be placed on the wall next to the base of the phone. Program Coordinator will train Program Specialists on what information is required to be on or near the phones. Habilitation Specialist and/or Program Specialist will verify that labels and/or signs are in the correct place and in good working order during the course of their monthly site visits. |
11/27/2013
| Implemented |
| 6400.74 | The steps next to the ramp in the garage do not have a nonskid surface. | Interior stairs and outside steps shall have a nonskid surface.
| Non skid tape has been placed on the steps in the enclosed garage by Direct Care Staff. From now on, Program Specialists will ensure that all steps in the residence have a non skid surface, both interior and exterior. Habilitation Specialist and/or Program Specialist will check the status of all steps during the course of their monthly site visits. Program Coordinator will train Program Specialists on ensuring that all interior and exterior stairs have a non skid surface. |
11/27/2013
| Implemented |
| 6400.164(a) | The medication log listed Individual #1 as being prescribed Quetiapine 20mg, take one tablet by mouth at bedtime. However, the current prescribed order for Individual #1 is Quetiapine 50mg, take one tablet by mouth at bedtime. In addition, the medication administration record for Individual #1 did not identify the month and year. | (a) A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication.
| Medication Log has been corrected by Program Specialist. A new medication management system has been developed and the Habilitation Specialists will be comparing the medication log to the prescription labels to verify accuracy prior to sending them to the residence. In addition, staff will be required to attend one of the two avoiding medication error trainings that are held at the agency twice a year. Program Specialist will also train Direct Care Staff to double check medication logs to prescription labels prior to signing logs. |
11/27/2013
| Implemented |
| 6400.167(b) | Individual #1 is ordered Clonidine 0.1mg, take 1 tablet in the AM and at noon and take 3 tablets at bedtime. However, the facility is administering 1 tablet of Clonidine 0.1mg at 8:00 AM and 3:00 PM and 3 tablets of Clonidine 0.1mg at 8:00 PM. | (b) Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant.
| Program Specialist has obtained a signed statement from the physician stating that she verbally authorized the change in administration instructions. In addition, prescription label information has been changed on the blister pack to accurately reflect dosage instructions. From now on, Program Specialists will requests that any and all medication changes are given in the form of a new prescription to ensure that the prescription label matches the medication log. Program Coordinator will train Program Specialists on regulation 6400.167(b) to ensure that these protocols are being followed. |
11/27/2013
| Implemented |
| 6400.213(9) | The ISP in Individual #1's record had an Annual Review Update date of 6/12/13 and had a fiscal year ending date of 6/30/13. The current ISP was not in the record. | (9) A copy of the current ISP.
| Program Specialist has placed a copy of the current ISP in the individual¿s file. From this point forward, when the Fiscal Department completes their weekly check for alerts in HCSIS, they will print out any updated ISP¿s and forward them to the Program Secretary who will place them in the appropriate file. In addition, Management Staff completing internal compliance audits will verify that Personal Data sheets have been accurately completed as part of their audit and will notify Program Coordinator of any discrepancies so that they can be corrected immediately. |
11/27/2013
| Implemented |