| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(2) | Individual #1 petty cash funds state that $20.49 was the ending balance of account at the end of February 2020. The starting balance of the account on 3/1/2020 states only $20.48 was available. | (2) Disbursements made to or for the individual.
| Individual #1 was reimbursed $.01 by RDS on 3.14.20. See attachment K. To prevent this from occurring in the future, the following process was put in place.
Each month the Program Specialist receives the petty cash forms by the 5th. At that time, the Program Specialist will log the ending balance on the petty cash log into a spreadsheet and email the Site Supervisor to verify that the ending balance that the Program Specialist has matches the starting balance of the current months petty cash log that is in use at the house. The Site Supervisor will reply to the email to verify the balances match and that the correct amount of money is there. The Program Individual #1 was reimbursed the $.01 on 3.14.20 by RDS. To ensure this issue it avoided in the furture this process was put in place by the Program Director as of 4.1.20. Specialist will review and verify the information on the petty cash log by the 12th of the month. If the log is entirely correct, the process is complete. If there are errors on the petty cash log and the error(s) change that ending balance, the Program Specialist will change the logged ending balance on the spreadsheet AND will email the Site Supervisor in order to have them correct the beginning balance on the current petty cash log in the home and ensure that the cash on hand matches. |
04/01/2020
| Implemented |
| 6400.166(a)(4) | Individual #1 medication administration records (mars) for February and March 2020 list that Tylenol was administered. After review of the individual's medications at home and speaking with the agency nurse on 3/12/2020, Individual #1 is administered Acetaminophen, the generic version of Tylenol. The actual name of the medication administered for the past two months, Acetaminophen, was not recorded on the mars. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | Medical Compliance Supervisor corrected the log on 3.3.20, see attachment J. A training on med admin documentation was done on 4.3.20 by the medical compliance supervisor so ensure staff are well trained on medication logs. |
04/03/2020
| Implemented |
| 6400.166(a)(9) | Individual #1 3/9/2020 medication administration record (mar) states that Imodium AD was delivered. The frequency recorded on the mar states, "2mg, give 2 tablets by mouth after loose stool. Then 1 capsule thereafter." The 10/8/19 physician's ordered dosage and frequency of Imodium AD states, "2 caplets by mouth after 1st loose BM, give 1 caplet by mouth after each loose BM thereafter but do not exceed 4 caplets per day for no more than 2 days." The entire frequency of the medication was not recorded on the mar. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | The additional frequency was added to the MAR on 3.30.20 by Medical Compliance Supervisor. As of 4.1.20, all OTC medications are now sent by pharmacy with labels that match identical to the medication log and will also be checked on site by the site supervisor. Please see attachment I. |
04/01/2020
| Implemented |
| 6400.166(a)(11) | Individual #1 medication administration records (mar) must include the reason for prescribing each medication at the time the medication was administered. Individual #1 psychiatrist prescribes Abilify to Individual #1 for Mood disorder but also Bipolar II disorder. Individual #1 February 2020 mar states that Abilify was administered for the month for a diagnosis of Insomnia, that does not match the psychiatrist's reason for prescribing the medication.
Individual #1 February 2020 mar does not include the reason for prescribing the Melatonin that was administered on February 8th, 10-14th, 17th, 19th, 22nd, and 23rd. According to the individual's physician, Melatonin is prescribed for Insomnia.
Individual #1 physician stated during 10/8/19 physical examination, that Individual #1 could be administered Tylenol 500mg for headache, fever above 99 degrees, and generalized aches/pains. Individual #1 February 2020 mar only includes the reason for prescribing the medication as, "headache, generalized aches/pains," but did not include fever above 99 degrees. | 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. | Insomnia was errored out and initialed by the medical compliance supervisor on 3.30.20. MC supervisor confirmed with psychiatrist and the correct diagnosis written for bipolar II disorder was added to the log. (see attachment F)
The reason for melatonin is sleep. It was written on the log by the Medical Compliance Supervisor on 3.30.20 as well as on the back of the log. See attachment G.
The complete reason for Tylenol us was added to the log by the Medical Compliance Supervisor on 3.30.20 and now includes "fever above 99 degrees". See attachment H.
MC Supervisor contacted pharmacy and as of 4.1.20, all OTC medications are now sent by the pharmacy with labels that match identically to the medication log. This will also be checked by Site Supervisors.
Medication documentation training occurred at this site on 4.3.20 and was provided by the medical compliance supervisor to review these issues and prevent them in the future. |
04/03/2020
| Implemented |
| 6400.166(a)(12) | Individual #1 has been residing in the residential home since 2/1/2020 under emergency respite status. Under this status, the medication record regulations are not exempt from licensing review and application of regulatory requirements. Individual #1 record was found to have three different medication administration records (mars) for February 2020. Two of the mars did not include a time of administration for Mirtazapine, aripiprazole, melatonin, and Tylenol that was administered throughout the month. The mars listed that the medications were administered at "bed" or "PRN" for their time of administration.
Tylenol 500mg was initialed as administered on 2/5/2020 and 2/6/2020 on the front of the mar. However, Tylenol 500mg was written as administered at 8am and 4:15PM on 2/5/2020, but not administered on 2/6/2020. The correct date of administration was not recorded.
The individual's March 2020 mars do not list a time of administration for Aripiprazole and Mirtazapine. The hours, minutes, and AM or PM is separated on different lines of the mar and does not clearly state the time administered. Assumptions would be made to determine time of administrations. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration. | Tylenol 500 mg - please see attachment E, I don't believe this is a citation, each date given is highlighted with complete documentation on the back of the log.
The current medication log states HS in the hour column with the exact time of sleep documented above staff initials. Medical Compliance Supervisor confirmed with all staff (on 3.27.20) who administered the med that it was given in the PM. All future medication logs will specify 8pm for HS medications as well as the EMARS. Medical Documentation Training for this site was done on 4.3.20 by the Medical Compliance Supervisor. See attachment F |
04/03/2020
| Implemented |
| 6400.166(b) | Individual #1 8AM 3/6/2020 medication administration record (mar) for Mirtazapine includes a note from staff #1 "3/6/2020 8AM med given but not initialed." The signature of the staff administering the medication on 3/6/2020 must be recorded on the mar at the time of administration.
Staff #2 initialed one of Individual #1 February 2020 medication administration records (mars) that Staff #2 administered mirtazapine, aripiprazole and melatonin to the individual on 2/31/2020; this is impossible as February only had 29 days in 2020. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Staff #1 did forget to initial the front of the med log for Florastor (not Mirtazapine) but did document on the back of the log and sign the med log. This is blackboxed on the log (see attachment C.) Staff #2 crossed out, error and initialed those dates for those medication. When Med Compliance Specialist discussed this with Staff #2, she was not sure why she had done this. She received counciling on this error by the Medical Compliance Supervisor. See attachment D. Documentation training was done on 4.3.20 for this site by the Medical Compliance Supervisor to prevent further errors and ensure staff were refreshed on documentation. |
04/03/2020
| Implemented |