| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.111(f) | At the time of the inspection, the fire extinguisher in the attic of the home did not have the current date of inspection on the tag. The fire extinguisher was marked as having last been inspected in January 2022. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | Fire Extinguishers are tagged with only the month and year. Companies stated that the extinguishers are good until the end of the month punched on the tag. To ensure that fire extinguishers are checked within the required 365 days, the companies utilized have been informed by the Facilities Director that inspections will be completed every 11 months. The quality assurance department will review this information during their bi-annual inspections. |
01/31/2024
| Implemented |
| 6400.141(a) | (.141d) - The TB was signed and dated by a Medical Assistant, not an RN/LPN/MD/CNP/PA-C as required by regulations. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter.
(.141d) - Immunizations, vision and hearing screening and tuberculin skin testing may be completed, signed and dated by a registered nurse or licensed practical nurse instead of a licensed physician, certified nurse practitioner or licensed physician's assistant. | The Licensed Physician Assistant typically has, in the past, completed the biennial TB noted on the annual physical form, however the Medical Assistant under the guidance of the CNP, read and initialed the TB results on the annual physical form. Going forward, the Program Manager will ensure the TB is read and signed by the Licensed Physician's Assistant, Physician, or Certified Nurse Practitioner. This was corrected at the time of the inspection and the correction was sent to the inspector on 12/1/23. |
01/31/2024
| Implemented |
| 6400.141(b) | Individual #1's physical exam was conducted on 4/14/23. However, the CRNP did not sign and date the form until 5/9/23. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | During the annual physical that occurred on 4/14/23 the PCP did not date or sign the physical form. When the PCP returned the annual physical, it was dated incorrectly. Going forward the Program Manager will ensure the PCP has dated and signed the annual physical form prior to leaving the physician's office. This was corrected at the time of the inspection and the corrected physical form was sent to the inspector on 12/1/23. |
01/31/2024
| Implemented |
| 6400.143(a) | (repeat from 1/17/23) Individual #1's doctor prescribed them to be on a 1500 calorie diet a day. From January 2023 through the present, Individual #1 had more than 1500 calories a total of 134 times. There was no documentation that Individual #1 was educated on the importance of following the dietary recommendations. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Individual #1 has a calorie restricted diet which is tracked in Therap under intake and elimination. Program Specialists document the monthly caloric intake in quarterly reports which are reviewed with, and a copy given to, the individual however no documentation of Individual #1 having received education of the importance of following their diet was documented on the quarterly report. Going forward, the Program Specialist will provide the individual with education on the importance of following the prescribed diet and document the education provided in the quarterly report. |
01/31/2024
| Implemented |
| 6400.144 | (repeat from 1/27/23) Individual #1's caloric intake is to be tracked daily. From January 2023 to the present, there were nine days the calories were not tracked. | 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 has a calorie restricted diet which is tracked in Therap under intake and elimination. Program Managers and their supervisory staff are required to review caloric intake monthly. T-Logs, along with Intake and Elimination will be utilized to review the documentation and ensure it has been completed. A menu is provided at each home that includes calorie counts for each food item which will be utilized to help with documentation of the calorie count. |
01/31/2024
| Implemented |
| 6400.165(c) | (repeat from 1/17/23) Individual #1's Escitalopram was to be tapered and discontinued beginning on 8/18/23. They were to take 20 mg for 7 days, 10 mg for 7 days, 5 mg for 7 days and then completely stop the medication. Individual #1 only took the 5 mg dose for 6 days. | A prescription medication shall be administered as prescribed. | After reviewing the eMARs from 9/1/23 through 9/7/23, it was discovered that the documentation for the escitalopram 5mg was not correct. The medication was administered correctly but not documented correctly on CaraSolva. The eMAR was rolled out at the beginning of 2023, during which time medication administrations were to continue to follow the ODP approved steps, including the documentation immediately after the individual takes his/her medications. Valley Community Services has recognized the difficulty of this system for medication administrators and administration has approved the procurement of a new, more user-friendly system. This entails changes with the pharmacy and re-education of all medication administrators. Once completed, the error for documentation will be addressed individually with the medication administrator and retraining must occur prior to permission to continue completing any medication administration. |
01/31/2024
| Implemented |
| 6400.166(a)(2) | (repeat from 1/17/23) Individual #1's November MAR did not list the prescriber for their Clobetasol. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | During review of the eMAR it was discovered that the prescribing physician was not listed on the eMAR for clobetasol 0.05% cream. The Program Manager corrected this at the time of the inspection and documentation was sent to the inspector on 12/1/23, proving the correction occurred. |
01/31/2024
| Implemented |
| 6400.166(a)(4) | Individual #1 was prescribed Triple Antibiotic Ointment to be administered twice a day for ten days starting on 7/20/23. This medication was not documented on the MAR with any of the required information. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | After reviewing the eMARs it was discovered that the documentation for the prescribed TAO was not correct. The medication was administered correctly but not documented correctly on CaraSolva. The eMAR was rolled out at the beginning of 2023, during which time medication administrations were to continue to follow the ODP approved steps, including the documentation immediately after the individual takes his/her medications. Valley Community Services has recognized the difficulty of this system for medication administrators and administration has approved the procurement of a new, more user-friendly system. This entails changes with the pharmacy and re-education of all medication administrators. Once completed, the error for documentation will be addressed individually with the medication administrator and retraining must occur prior to permission to continue completing any medication administration |
01/31/2024
| Implemented |
| 6400.166(a)(14) | Individual #1 was prescribed Nitrofurantoin on 1/31/23. The MAR does not indicate the duration of days the medication is to be administered. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Duration of treatment, if applicable. | In reviewing the eMAR, it was noted that the Program Manager accepted the medication but did not clarify in the scheduling section that the medication was to be given for a specified time period. The individual only received the prescribed doses of the medication. Without the stop date in the system, staff may have exceeded the prescribed time frame. |
01/31/2024
| Implemented |
| 6400.166(b) | From January 2023 to the present, there were 437 medication administrations that were not logged immediately. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The eMAR was rolled out at the beginning of 2023, during which time medication administrations were to continue to follow the ODP approved steps, including the documentation immediately after the individual takes his/her medications. Quality Assurance has been conducting retraining at all the CLAs regarding the requirement to mark the medication administration as completed prior to the end of the allotted window. Valley Community Services has recognized the difficulty of this system for medication administrators and administration has approved the procurement of a new, more user-friendly system. This entails changes with the pharmacy and re-education of all medication administrators. Once completed, the error for missing the window to document will be addressed individually with the medication administrator and retraining must occur prior to permission to continue completing any medication administration. |
01/31/2024
| Implemented |
| 6400.167(a)(1) | Individual #1 was prescribed Flucanozole on 7/26/23 for a UTI. It was not administered to Individual #1. On 9/26/23, Lotrisone cream was ordered to use daily for Individual #1. This medication was not administered to the individual. Individual #1 was not administered their Triple Antibiotic Cream on 11/1/23 at 8pm. | Medication errors include the following: Failure to administer a medication. | After reviewing the eMARs from 7/23/23, Fluconazole, and 9/26/23, It was discovered that the documentation was not correct. The medications were administered correctly but not documented correctly on CaraSolva. The eMAR was rolled out at the beginning of 2023, during which time medication administrations were to continue to follow the ODP approved steps, including the documentation immediately after the individual takes his/her medications. Valley Community Services has recognized the difficulty of this system for medication administrators and administration has approved the procurement of a new, more user-friendly system. This entails changes with the pharmacy and re-education of all medication administrators. Once completed, the error for documentation will be addressed individually with the medication administrator and retraining must occur prior to permission to continue completing any medication administration. |
01/31/2024
| Implemented |
| 6400.181(f) | Individual #1's legal guardian, Distinctive Human Services was not provided a copy of the assessment completed on 4/2/23. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The Program Specialist did not provide a copy of Individual #1's assessment to their legal guardian. Going forward, the legal guardian will be sent a copy of the annual assessment, and this will be documented in the assessment and the assessment letter. |
01/31/2024
| Implemented |
| 6400.183(a)(3) | There were no direct care staff present at the ISP Team meeting held on 6/13/23 for Individual #1. | The individual plan shall be developed by an interdisciplinary team, including the following: The individual's direct care staff persons. | The Program Manager was present at the ISP meeting and does work directly with Individual #1 however a DSP was not present at the ISP meeting. There were 3 members of the team present at the ISP which meets the requirement of regulation 6400.183(b) Going forward, DSP's will be asked to attend the ISP meeting. |
01/31/2024
| Implemented |
| 6400.196(b) | Individual #1 has a "hands down" restrictive procedure in place. There is no documentation that staff experienced use of the restrictive procedure. | If a physical restraint will be used, the staff person who implements or manages the behavior support component of the individual plan shall have experienced the use of the physical restraint directly on the staff person. | The Safety Mechanics training that is taught at VCS includes the use of holds and those holds are demonstrated on the participating staff as part of the annual training. The syllabus for Safety Mechanics does not describe the use of the hold being taught as being demonstrated on the participating staff. Going forward, the syllabus will include the hold that is taught as being demonstrated on the participating staff. |
01/31/2024
| Implemented |