| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.144 | Individual #1 was prescribed Debrox ear drops by the audiologist due to excessive ear wax on 6/9/20. This medication was not administered until 9/9/20. Individual #1 began to complain of ear pain and had asked to see a doctor on Sept 21, 22nd & 23rd, 2020, which was written on the Health Service notes in individual's daily book. It was also documented on the Sept 2020 MAR's that Individual #1 had refused the Debrox three times, which staff indicated is unusual. While conducting the home inspection, the State Inspector heard Individual #1 say their ear hurt. | 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.
| Individual #1 was offered to be taken to Med Express on 9/23/2020 but declined due to the wait time. She was instead taken on the morning of 9/24/2020 and was prescribed an antibiotic, Olfoxacin, on the 24th and administration was started on the same day.
An email was sent to all house Supervisors as well as Program Specialist reminding them to follow the guidelines of regulation 144 to start medications timely when prescribed. |
10/08/2020
| Implemented |
| 6400.32(r) | Individual #2 and#3 did not have a lock on their bedroom door, and they were not assessed if they wanted a lock or not. | An individual has the right to lock the individual's bedroom door. | Program Specialist spoke with Individuals #2 and #3 regarding whether they would like locks on their bedroom doors. Individual #2 said she would like a lock with a key and Individual #3 decided she did not want a lock. On 9/30/2020 work orders were submitted to have door knobs changed and extra keys were made for Individual #2's lock. Assessment addendums and ISP updates were sent for all ladies in the home to have updated information.
Excentia's annual Assessment form has been changed to include information regarding assessing a persons desire to lock their bedroom door as well as assessing the type to locking mechanism to be used. |
10/08/2020
| Implemented |
| 6400.32(r)(5) | Individual #1 has a lock on the bedroom door, but staff in the home did not have the key on their person in case of an emergency. | Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door. | Program Specialist, had extra copies of keys made of the Individual #1's key for her door. A labeled copy of this key was added to a lanyard for staff to carry with them at all times when in the home. Extra copies were made and placed on various options that staff can carry on them, including a wrist band. These were also labeled. A document explaining this need was also created for staff working in the home to read and sign as acknowledgement of this requirement. |
10/08/2020
| Implemented |