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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.144 | On 6/5/2020 Individual #1's podiatrist stated that they recommended Individual #1 soak his foot for 20 minutes, 2 times daily for 3 days along with applying antibiotic ointment to his foot due to ingrown toenails, sore toes, and Tinea Pedis. There is no evidence that the podiatrist's recommendations were followed. | 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 treatment ended after 3 days. These records are unable to be reconstructed or updated to show current compliance.
Evaluation of the non-compliance and interview with responsible staff demonstrated a failure to recognize the need to record an OTC order in our QuickMar system and record similar to prescription medications. Responsible staff received disciplinary action inclusive of technical guidance/remediation on the reporting and recording practices for OTC orders as follow up per med admin training. Reviews of medical consults will continue to occur by medical and programming staff to monitor compliance.
Attached is copy of disciplinary action inclusive of technical guidance/remediation for responsible staff (16) and reviewed medical consult subsequent to licensing review (12). |
08/12/2020
| Implemented |
| 6400.181(e)(9) | Individual #1's 9/15/19 assessment does not include a list of his current diagnosis. According to his medication administration records, he is administered medications for Bipolar disorder unspecified, Hyperlipidemia, Attention-Deficit Hyperactivity Disorder, elevated blood pressure, Sleep disorder, and Tinea Pedis. These diagnoses are not included in his assessment. According to physician's documentation throughout his record, he also has been diagnosed with Supraventricular tachycardia (SVT), Paroxysmal Supraventricular Tachycardia (PSVT), and Obsessive-Compulsive Disorder (OCD) that are not included in his assessment. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | The individuals assessment has been updated and distributed to his team inclusive of all identified diagnosis. Diagnosis history is reported on the Lifetime Medical History under Current Health Status. Technical assistance was provided by the Facility Director regarding the non-compliance and applicable regulation on 8/4/20. The responsible Program Specialist completed a review of remaining assessments to identify any other discrepancies and correct. This resulted in additional updates. An example is attached and referenced (15).
In order to streamline and provide consistent information in the assessment, the template for lifetime medical history was updated for use by Program Specialists. The LTMH is attached to the annual assessment. Program Specialists will now identify diagnosis in the following categories: those identified by psychiatrist, those identified by PCP, `other diagnosis, and identifying medications with their prescribed reason. This template will require aggregating data from specified data sources for easier cross-referencing and reduced omission rates. For ongoing monitoring of compliance, a sample specific to this Program Specialist will be selected in the upcoming LII self-assessment
Attached is applicable section of individuals assessment with updated information utilizing the updated template (13), record of feedback (14), and an additional assessment completed since licensing review utilizing amended template (15). |
08/12/2020
| Implemented |
| 6400.165(b) | Individual #1's prescription order for Perphenazine 8mg is not kept current. According to his physician's written order on 11/21/19, he is to be administered Perphenazine, may give 2 tablets 1 hour prior to anxiety/agitation provoking events or for continued agitation/anxiety, not to exceed 3 doses in 24 hours. His physician wrote another order on 2/6/2020 to state the medication should be administered, 2 tablets by mouth 1 hour prior to events likely to provoke severe agitation or anxiety, or for confirmed agitation, not to exceed 3 doses per day. The medication administration record and medication label stated take 2 tablets by mouth as needed every hour, not to exceed doses in 24 hours. According to the provider, the medication is to be administered as needed every hour for anxiety and as needed 1 hour prior to any anxiety provoking events.
Individual #1's current order for Clotrimazole cream was updated by his physician on 1/21/2020 to be applied to affected areas of feet as needed. The medication label on Clotrimazole cream at the home was not updated to include the current order. The medication label stated to apply to the affected area every day. | A prescription order shall be kept current. | The PRN order was updated to reflect cumulative previous guidance from prescriber. Additionally, the MAR has been corrected to reflect the current updated PRN order for this individual. Nursing Supervisor completed a review of all current PRN orders to insure accurate reflection in QuickMar which is our electronic MAR system. This review included the directions for use and creation of fields for selecting reason, authorizer, and outcome recording.
As a result of nursing review, an oversight in our compliance checks was discovered. While med reviews and medical consults are all reviewed by nursing staff in order to maintain consistency of records, PRN orders were not being distributed to nursing staff for review. This protocol has been amended. Nursing staff will review all PRN orders similar to all other medical documentation in order to monitor ongoing compliance. PRN orders are compared to QuickMar data and require validation by nursing staff.
The cream medication label has been corrected to reflect the current order. Records were obtained from prescriber indicating that staff contacted their office at resolution of initial foot issue. Directions for administration were amended, however, staff failed to complete a medical consult for this correspondence. As a result, typical nursing reviews did not occur and no further validation was done to update the medication label. The medication was not subsequently administered resulting in no cross checks between label and QuickMar at time of administration.
Staff responsible for failing to submit a timely medical consult received disciplinary action as a result of their inaction. Technical guidance was also provided as follow up to disciplinary action. Technical guidance was provided to site supervisor to reinforce oversight of support staff duties regarding timely submission of required reports and need to update medication labels. Reviews of medical consults will continue to occur by medical and programming staff to monitor compliance. All staff assigned to the home will have two med pass observations completed by medical staff by end of August. Records of training will be sent as addendum to POC.
Attached is updated PRN form from recent medical consult (4), copy of current MAR and med label reflecting consistent info from PRN form (5), email correspondence to all program staff reflecting review of PRN orders in QuickMar (6), and email correspondence to responsible staff regarding change in protocol for PRN reviews by medical staff (7), corrected medication label (8), current MAR reflecting medication (9), copies of disciplinary action inclusive of technical guidance for both support staff and site supervisor (10), and reviewed medical consult subsequent to licensing review (12). |
08/06/2020
| Implemented |
| 6400.166(a)(9) | Individual #1's prescribing nurse practitioner added new frequency directions to his Perphenazine psychotropic medication on 11/21/19. As of 11/21/19, the individual is prescribed Perphenazine 8mg, take 2 tablets as needed every hour for anxiety and also may give 2 tablets 1 hour prior to anxiety/agitation provoking events, not to exceed 3 doses in 24 hours. Individual #1's medication administration records (mars) from November 2019 to current, did not include both frequency directions; the mars only stated to administer 2 tablets as needed every hour, not to exceed 3 doses in 24 hours. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | The MAR has been corrected to reflect the current updated PRN order for this individual. Nursing Supervisor completed a review of all current PRN orders to insure accurate reflection in QuickMar which is our electronic MAR system. This review included the directions for use and creation of fields for selecting reason, authorizer, and outcome recording.
As a result of nursing review, an oversight in our compliance checks was discovered. While med reviews and medical consults are all reviewed by nursing staff in order to maintain consistency of records, PRN orders were not being distributed to nursing staff for review. This protocol has been amended. Nursing staff will review all PRN orders similar to all other medical documentation in order to monitor ongoing compliance. PRN orders are compared to QuickMar data and require validation by nursing staff. All staff assigned to the home will have two med pass observations completed by medical staff by end of August. Records of training will be sent as addendum to POC.
Attached is updated PRN form from recent medical consult (4), copy of current MAR reflecting consistent info from PRN form (5), email correspondence to all program staff reflecting review of PRN orders in QuickMar (6), and email correspondence to responsible staff regarding change in protocol for PRN reviews by medical staff (7). |
08/06/2020
| Implemented |
| 6400.186 | Individual #1's restrictive procedure plan, outlined in his Individual plan, states that the telephone is to be made inaccessible to him due to his continued attempts to contact 911. A house telephone was found located on the kitchen counter, sitting in the charging station and accessible to Individual #1. Staff person #1 confirmed that the telephone is always positioned on the kitchen counter in the home.
Individual #1's plan also states that he is to have frosting tint on the lower portion of his bedroom windows. During the 7/23/2020 onsite inspection, approximately 1 inch of frosting appeared to be scraped away from the bottom of the lower portion of his window that faced the back yard. Due to this, that portion of his window was not equipped with the frosting tint. This allowed clear vision through the window where the frosting was scraped off. Both windows in his bedroom that contained the frosting, contained multiple spots, approximately ¼ inch in diameter, where the frosting appeared to be scratched off the window. | The home shall implement the individual plan, including revisions. | Individuals team reviewed phone and frosting restrictions to insure its continued need and applicability. Both restrictions were found to be appropriate and in need of continuation. The phone was removed from being accessible in a common area on the same day the violation was noted. This type of restriction is not a part of any other restrictive plans within our program.
Touch up frosting was applied to the noted areas to bring the window into compliance. Behavior Specialist reviewed all similar restrictions in current BSPS and confirmed compliant window coverings.
Staff development occurred relative to this restriction identified in BSP for all support and programming staff. Training was provided by Behavioral Specialist and Program Team. This was completed on 8/10/20. The LII physical site tool will be used to review all sites quarterly by a designated Program Manager in order to monitor ongoing compliance. This assignment will include meeting with Behavior Specialist specific to a home in order to review any physical site modifications that are to be monitored during inspections. This will allow for a more comprehensive review of similar issues. Records of these inspections will remain filed with full LIIs annually.
Attached is training documentation for BSP inclusive of this restriction (1), picture of corrected window (2) and record of record review by Behavior Specialist (3). |
08/10/2020
| Implemented |
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