| 6500.17(a) | The self-Assessment for this home was completed 9/26/23- 10/13/23. The home self-assessment was not completed within 3-6 months prior to the licensing expiration date of Nov 10th, or 3-6 months after the last licensing period which occurred February 2023. | If an agency is the legal entity for the home, the agency shall complete a Self-Assessment of Homes the agency is licensed to operate within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. | Program Director and Executive Director reviewed the self assessment process/regulation and determined the dates that would be used to meet the regulation. Program Director put all information in an email on 3.7.24 (attachment #1) and sent it to all program staff so the schedule could be reviewed. |
03/07/2024
| Implemented |
| 6500.135(e) | Individual #1's MAR indicated that Denta 5000 plus cream was to be given twice daily for the months of December 2023 and January 2023. It also indicated that individual #1 was to be given a similar dental toothpaste medication called SF 1.1% Gel daily. The MAR was not updated to reflect the change in medication until February 2024, but the change in medication brands occurred in July of 2023 per documentation.
Individual #1's February 2024 medication administration record states that they are prescribed Robafen DM Syrup 100, Siltussin SA 100 mg, and DM Cough Syrup. At the time of the inspection, only DM Cough Syrup was available in the home. | Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received. | MAR was corrected for February, 2024. RDS LPN contacted the dentist office on 2.28.24 and confirmed that Sodium Flouride is the only active order that they want her to be using. Current MAR is reflecting Sodium Flouride 1.1% Gel one time a day as prescribed by the dentist. Record of MAR is attachment #4(a)
No other homes had this issue.
MAR was corrected on 3.8.24 by RDS LPN contacting the Pharmacy and getting new MARS printed with only one cough syrup on the MAR to reflect the cough syrup that is in the home. Record of MAR is attachment 4(b)
No other homes had this issue. |
03/08/2024
| Implemented |