Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.62(a) | Poisons were left unlocked in the main floor bathroom during the inspection. (Lysol spray, Febreeze, Chlorox wipes, Steramine and others) | Poisonous materials shall be kept locked or made inaccessible to individuals. | All staff were retrained on this regulation on 9-19-22. The items found to be unlocked were immediately locked up. |
09/19/2022
| Accepted |
6400.64(f) | Outside trash receptable at the side of the house was overflowing so that the lid would not close. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | The team was retrained on 9-19-22 in regards to this regulation. The team was spoken to and they stated that the trash does not usually overflow and they were retrained in this regulation. The home will also be purchasing a larger trashcan. |
09/19/2022
| Accepted |
6400.144 | REPEAT FROM 3/22/22. Calmal 4 suppository was not given on at bedtime on July 3rd and 4th. When questioned about this, staff stated it was because they did not have the medication. | 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.
| Staff were retrained immediately on this regulation. The entire residential department was retrained on 9-19-22. |
09/19/2022
| Accepted |
6400.214(b) | REPEAT FROM 3/22/22. Most current record information was not available in the home | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| The current record was missing the most up to date ISP. This was printed and filed on 7-11-22. The residential management team was retrained on this regulation by Leo Marcantonis on 9-16-22. |
09/16/2022
| Accepted |
6400.50(a) | REPEAT FROM 3/22/22. CPAP and Diabetes trainings did not list the duration of the trainings | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | The original training log can not be located in order to go back to add the duration of the training. All trainers were retrained on 9-19-22 to ensure that all internal trainings have a training log and that the log is handed in to HR in order to be documented in our Relias Training system. |
09/19/2022
| Accepted |
6400.163(d) | Hydrocortisone Cream 1% was lying on a desk in the basement during the inspection. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | All staff were retrained on this regulation on 9-19-22. The item found to be unlocked was immediately locked up. |
09/20/2022
| Accepted |
6400.166(a)(2) | REPEAT FROM 3/22/22. Name of prescriber not listed on any of the MARs. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | All Management in Residential were re-trained by Leo Marcantonis, Director of Residential Services, on 9-19-22 explaining 6400 regulations regarding administering and documenting medications according to regulatory timeframes. All management in Residential were retrained in regards to ensuring the Name of the Prescriber is listed on the MAR. |
09/19/2022
| Accepted |
6400.166(a)(5) | REPEAT FROM 3/22/22. Jan 22 MAR for polyethylene glycol missing strength of medication, | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | All Management in Residential were re-trained by Leo Marcantonis, Director of Residential Services, on 9-19-22 explaining 6400 regulations regarding administering and documenting medications according to regulatory timeframes. All management in Residential were retrained in regards to ensuring the strength of the medication is listed. |
09/19/2022
| Accepted |
6400.166(a)(6) | REPEAT FROM 3/22/22. Jan 22 MAR for polyethylene glycol missing dosage form | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | All Management in Residential were re-trained by Leo Marcantonis, Director of Residential Services, on 9-19-22 explaining 6400 regulations regarding administering and documenting medications according to regulatory timeframes. All management in Residential were retrained in regards to ensuring the dosage form is listed accurately on the MAR. |
09/19/2022
| Accepted |
6400.166(a)(7) | REPEAT FROM 3/22/22. Jan 22 MAR for polyethylene glycol missing dose of medication | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | All Management in Residential were re-trained by Leo Marcantonis, Director of Residential Services, on 9-19-22 explaining 6400 regulations regarding administering and documenting medications according to regulatory timeframes. All management in Residential were retrained in regards to ensuring the dosage is listed accurately on the MAR. |
09/19/2022
| Accepted |
6400.166(a)(9) | REPEAT FROM 3/22/22. Jan 22 MAR for polyethylene glycol missing frequency of administration, | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | All Management in Residential were re-trained by Leo Marcantonis, Director of Residential Services, on 9-19-22 explaining 6400 regulations regarding administering and documenting medications according to regulatory timeframes. All management in Residential were retrained in regards to ensuring the frequency is listed accurately on the MAR. |
09/19/2022
| Accepted |
6400.166(a)(11) | REPEAT FROM 3/22/22. Jan 22 MAR for polyethylene glycol missing diagnosis | 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. | All Management in Residential were re-trained by Leo Marcantonis, Director of Residential Services, on 9-19-22 explaining 6400 regulations regarding administering and documenting medications according to regulatory timeframes. All management in Residential were retrained in regards to ensuring the diagnosis is listed accurately on the MAR. |
09/19/2022
| Accepted |