| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.163(c) | Individual #3 had no psychiatric medication review in the record for the quarter 09/16-12/16. The most recent psychiatric review was dated 06/02/16. Individual #3 is prescribed Aripiprazole (Abilify) 10 mg 1 tab 1 x/day @ 8 am for Paranoia, delusions. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | 163(c)- If a medication is prescribed to treat a psychiatric illness, is there a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage?
Individual #3 is seen every 3 months by a licensed physician due to him taking Aripiprazole (Abilify) for Paranoia, Delusions. On 11/9/16 and 8/16/16, the medication review form was not taken to these appointments so it was attempted to have the physician sign off on a health service record stating these appointments occurred.
In the future, the Supervisor as well as the Associate Director/Program Specialist will assure that the appropriate 3 month medication review form is brought to all Medication Reviews. If a form is forgotten, it will be up to the Supervisor and Associate Director/Program Specialist to return to the physician¿s office to have the appropriate forms signed off on that confirm the reason for prescribing the medication, the need to continue the medication and the necessary dosage.
Attached you will also find the 3 month medication review forms for Individual # 3 and Individual A to show we have come into compliance with this regulation. |
03/01/2017
| Implemented |
| 6400.164(b) | On June 24, 2016, the medication Phenobarb 32.4 mg tab take 1 tab 2x/day for seizures was not documented on the 8 AM med log. No initials on the record nor documentation on the back of the medication log that the medication was given to Individual # 3. On June 30, 2016 the medication Pilocarpine sol 4% op - Instill 1 drop in left eye 4x daily for glaucoma was not documented on the medication log. The 06/30/16, 9 pm drops were not signed/initialed as given. The medication log was blank and not documentation on the back of the medication log. | The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. | 164(b)- Is the information specified in 164(a) logged immediately after each individual¿s dose of medication is administered?
On June 24th, 2016, the medication Phenobarb 32.4 mg was not documented on the 8 am med log. The June 30th, 2016, the medication Pilocarpine sol 4% was not documented on the medication log. Also on that same date, the 9pm drops were not recorded as well.
In the future, the Supervisor as well as the Associate Director/Program Specialist will assure that immediate documentation of medications is taking place. Failure to do so will result in disciplinary action for not only the person who missed documenting, but also each person who administered medication after the missed initial. The Supervisor as well as the Associate Director/Program Specialist will continue to review each med log to assure all time slots are properly filled out.
Attached you will also find Medication Logs for Individual A, Individual B and Individual #3 to show we have come into compliance with this regulation. |
03/01/2017
| Implemented |
| 6400.186(c)(2) | Individual # 3 has a seizure protocol in the Individual Support Plan but the seizure protocol was not reviewed in the following quarterly reviews dated 12/2/16, 09/12/16, 06/08/16 and 03/10/16. | The ISP review must include the following: A review of each section of the ISP specific to the residential home licensed under this chapter. | 186(c)(2)- Does each review include a review of each section of the ISP specific to the facility licensed under this chapter?
Individual #3 has a seizure protocol in his Individual Support Plan but the seizure protocol was not reviewed in the quarterly reviews.
In the future, the Program Specialist will assure that seizure protocols are clearly stated and reviewed with all the quarterly reviews sent to the team. Appropriate documentation will occur under the update section.
Attached you will also find the quarterly ISP review for Individual #3 and for Individual A to show we have come into compliance with this regulation. |
03/01/2017
| Implemented |