Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.106 | Furnace inspections completed on 1/18/2021, 4/22/2021, 7/06/2021, and 10/12/2021 were not completed by a professional furnace cleaning company. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| We previously had our maintenance manager completing the furnace inspections for all homes. The Residential Director contacted and scheduled to have Central Heating and Plumbing inspecting the furnaces at all locations on 12-15-2021 and 12-16-2021. |
12/16/2021
| Implemented |
6400.163(h) | Individual #1, date of admission 3/12/2021, had the following medication discontinued on 8/29/2021: Biofreeze (4%) - Apply to the affected area up to 4 times per day as needed. This medication remained with Individual #1's current medications. This medication was not destroyed in a safe manner according to Federal and State statutes and regulations. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | On 11-17-2021, the Residential Director removed the topical medication from the home and destroyed of it in the proper and safe manner. Please note none of this medication was administered after the discontinued date. |
12/10/2021
| Implemented |
6400.166(a)(7) | Individual #1, admission date 3/12/2021, is prescribed the following medication: Fluticasone Propionate 50 micrograms (mcg)/Act - Instill 2 sprays into each nostril everyday as needed. The November 2021 Medication Administration Record for Individual #1 has the medication dosage listed as follows: Fluticasone Propionate Nasal Spray 50 milligrams (mg) - Instill 2 sprays into each nostril daily. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | On 11-17-2021, the Residential Director corrected the dose label on the MAR. Please note that the individual received the correct dosage of medication when administered. However, the staff wrote 50mg instead of 50mcg. |
12/10/2021
| Implemented |
6400.166(d) | Individual #1, admission date 3/12/2021, is prescribed the following medication: Polyeth Glyc Pow 3350 NF - Drink one-half capful (8.5 GM) mixed in water on Monday, Wednesday and Friday. May increase to one capful (17 GM) every day if no bowel movement in two days. The November 2021 Medication Administration Record for Individual #1 has the following directions listed: Polyeth Glyc Pow 3350 NF - Mix half capsule in 8 oz. of liquid and drink Monday, Wednesday and Friday.
Individual #1, admission date 3/12/2021, is prescribed the following medication: HM Gas Relief 125 MG Softgel - Take one capsule by mouth before meals. The November 2021 Medication Record for Individual #1 has the following directions listed: HM Gas Relief 125 MG Softgel - Take one capsule by mouth three times daily with meals. | The directions of the prescriber shall be followed. | On 11-17-2021 the Residential Director corrected the MAR to read exactly how the prescriber ordered. |
12/10/2021
| Implemented |