| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Individual 2's plan indicates poisons must be kept locked up as they are not poison safe. Toilet bowl cleaner and spray cleaner were found on the ground of the first floor ½ bath near the toilet. Two bottles of bleach were found in an unlocked kitchen cabinet to the right of the oven. An unlocked container in the supply room closet was found to have Lysol, Dawn detergent, dryer sheets, and other cleaning supplies. Individual 1's plan also indicates they are not poison safe; disinfectant sprays and antibacterial wipes were found in an unlocked wardrobe in their room. Antibacterial soap was found on Individual Stephan 3's bathroom sink, and bleach and disinfectant spray were stored in the unlocked cabinet beneath their sink; their plan also indicates they are not poison safe. | Poisonous materials shall be kept locked or made inaccessible to individuals. | All poisonous materials must be locked. A locked cabinet is located in the Program Manager¿s office on the first floor for large containers of soap and cleaning supplies. Personal care kits and kits for personal care every two hours or as needed is located in the hall closet across from the bathroom on the first floor, also locked. All staff have been trained on safe chemical storage within the home. |
10/31/2022
| Implemented |
| 6400.64(a) | A pillow was found on Individual 2's bedside end table that was partially crusted with a white or cloudy material. Staff removed the pillowcase to be washed during the inspection. | Clean and sanitary conditions shall be maintained in the home. | A plan of care was created to enhance Individual #2¿s healthy environment. The plan calls for daily cleaning of Individual 2's bedding due to drooling. The Plan of Care was added to THERAP an electronic record for staff to review. The plan of care will be monitored by the Program Manager. |
11/02/2022
| Implemented |
| 6400.66 | There is no light at the bottom landing of Individual 3's bedroom staircase. There was also no exterior light outside of the basement door. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| A light was installed at the bottom of the interior stairway. A light will be installed outside the basement door once the cost is assessed and approved. |
11/30/2022
| Implemented |
| 6400.67(a) | The baseboard radiator near the first-floor half bath is broken and falling away from the wall. The blinds on the window on the first floor ½ bath are missing a slat, and the blinds on the left window in the supply room were missing between 11 and 12 slats. The blinds on the right window in Individual 1's room were non-operational---they cannot be raised. | Floors, walls, ceilings and other surfaces shall be in good repair. | The blinds were replaced and the radiator cover was fixed. Due to the age of the radiator covers, a quote was obtained to replace all of the radiator covers. ($ 9,000.00+) This will be completed as the home is often requesting repair to the current radiator covers.
Individual 1 now has curtains as the blinds were not suitable. |
11/04/2022
| Implemented |
| 6400.67(b) | Water was found pooled on the floor in an unused bathroom space in the basement, coming from an unknown source, creating a mold hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The basement floor is dry. The old bathroom was completely removed from the basement including excess plumbing. |
11/01/2022
| Implemented |
| 6400.77(b) | The house's first aid kit did not have bandages. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | The first aid kit was replaced including an assortment of adhesive bandages. It is the responsibility of the Program Manager to make sure all First Aid kits have adequate supplies. |
10/31/2022
| Implemented |
| 6400.81(i) | Individual 1's bedroom windows did not have blinds or drapes. | Bedroom windows shall have drapes, curtains, shades, blinds or shutters. | Individual #1 had curtains installed on both bedroom windows. |
10/31/2022
| Implemented |
| 6400.144 | Individual 2's diazepam medication blister pack was missing 3 tablets. Logs showing administrations were requested; the log the agency provided was blank. | 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.
| CADES medication procedures have been updated to include the following steps:
1. Emergency Refills
a. The Residential Manager will check all medications every Thursday to determine the need for refills.
b. The House Supervisor will check all medications every Tuesday to determine the need for refills.
c. The Nurse will check all medications once per month, two weeks prior to cycle med check-in to determine the need for refills.
i. The designated staff will:
1. Ensure there is always a minimum of three days supply of each medication.
2. Notify the pharmacy of any medications needed.
3. Ensure that any medication ordered is delivered and communicate via team email and document in communication log any follow-up that is required needed when ordered medications are not delivered within 24 hours.
4. Sign the back of the MAR in the notes section that they completed a medication refill check with the date of the check.
2. Emergency Orders
a. To prevent any medication errors, because a medication was not delivered to a program, the following should be implemented:
i. Each program should have regular ordering procedures to be pro-active and ensure medications are available when needed. Whenever the last dose of a medication is administered, staff should immediately act to ensure medication for the next dose is available by the time it is needed and notify their supervisor and nurse that the potential for an error is present.
b. If medications do not arrive on time, and the contracted pharmacy is closed or not able to deliver the medication in time, staff or nurse should:
i. Notify the Program Manager, Nurse or the on-call so they can call the primary physician and ask them to call in a prescription for the needed medication in a quantity just enough to last until the regular pharmacy can fill and deliver the needed medication. The order should not exceed a 3-day supply.
ii. The Nurse or On-call nurse will request the script be sent to the closest 24-hour CVS pharmacy and ensure that the pharmacy has the information needed to cover the cost of the prescription.
iii. The Program Manager or on-call will assist to ensure medication arrives in a timely manner.
3. Medication Reviews and Audits
a. Overnight Medication Checks - DSP
i. Staff in each CLA shall conduct daily medication checks for each individual during the overnight shift.
ii. The DSP will utilize the Overnight Medication Checklist to conduct their review
iii. Program Managers will ensure that shift assignments are completed and posted for staff on each shift; with medication inspection identified among priority tasks on the assignment sheet. If the overnight staff is not medication administration certified, the Program Manager will assign the responsibility to a first shift staff or 2nd shift staff that is medication administration certified.
iv. Upon reporting on duty, staff (DSP) will review the shift assignment and identify staff assigned to inspect medications.
v. Assigned staff will:
1. Complete the checklist and sign and date it.
2. Report discrepancies identified in the medication checklist process to the Supervisor On-call
3. Report discrepancies in an Scom via email to the Program Manager and Nurse for follow up.
4. Complete the appropriate documentation on the MAR.
vi. Within 24 hours, the Program Manager or Manager On-call (weekends only) will follow up on reported items and communicate via email to the CLA team, CLA Program Director and Director of Clinical Services.
b. Program Audits
i. Weekly medication audits will be conducted by members of CLA management team to ensure compliance.
1. The Residential Manager will complete an audit every Thursday
2. The House Supervisor will complete an audit every Tuesday
3. The Nurse will complete an audit once per week of each CLA on their caseload.
ii. The designated staff will:
1. Utilize the Program Audit Medication Checklist to conduct their audit
2. Report discrepancies identified in the medication audit via scom to the Program Manager and nurse for follow up.
3. Sign the back of the MAR in the notes section that they completed a MAR audit with the date completed.
iii. Within 24 hours, the Program Manager will follow up on reported items and communicate via email to the CLA team, CLA Program Director and Director of Clinical Services.
iv. Submit weekly audits to the CLA Administrative Assistant along with the Controlled Substance Count Record each week.
v. Data will be reviewed monthly in the CLA medication review meeting. |
11/04/2022
| Implemented |
| 6400.163(g) | Individual 2's loratadine had a ripped blister pack compartment, exposing one of the tablets; it was taped over during the inspection. | Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions. | CADES medication procedures were re-trained, covering the following steps:
1. Labeling/Containers
¿ Containers that are soiled, cracked, or without secure closures will not be used and will be returned immediately to the pharmacy to re-package. |
11/04/2022
| Implemented |
| 6400.165(b) | Individual 2's MAR indicates triple antibiotic ointment should be applied to affected area for cuts and scrapes as needed, but the pharmacy label indicates it should be applied four times a day to affected areas. | A prescription order shall be kept current. | CADES medication procedures were re-trained, covering the following steps:
1. Labeling/Containers
The medication label must be immediately sent back to the pharmacy for a new label if the label does not match the medication order |
11/04/2022
| Implemented |
| 6400.166(a)(13) | Numerous medications on Individual 2's MAR were missing signatures for different days' administrations. Pantoprazole Sodium DR 40 mg. was missing signatures on 4/1/22, 4/11/22, 4/13/22, and 4/18/22. Risperidone 1 mg tablets was missing signatures for 8AM administrations on 4/11/22 and 4/18/22. Divalproex sodium 125 mg was missing signatures for the 8AM administrations on 4/1/22, 4/11/22, 4/18/22, and the 12PM administrations on 4/17/22, 4/18/22, and 4/19/22. Their multivitamin was missing signatures on 4/1/22, 4/11/22, and 4/18/22. Their MAR and medication log for their Lorazepam do not have signatures for the administration on 4/18/22. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | Medication Reviews and Audits
a. Overnight Medication Checks - DSP
i. Staff in each CLA shall conduct daily medication checks for each individual during the overnight shift.
ii. The DSP will utilize the Overnight Medication Checklist to conduct their review
iii. Program Managers will ensure that shift assignments are completed and posted for staff on each shift; with medication inspection identified among priority tasks on the assignment sheet. If the overnight staff is not medication administration certified, the Program Manager will assign the responsibility to a first shift staff or 2nd shift staff that is medication administration certified.
iv. Upon reporting on duty, staff (DSP) will review the shift assignment and identify staff assigned to inspect medications.
v. Assigned staff will:
1. Complete the checklist and sign and date it.
2. Report discrepancies identified in the medication checklist process to the Supervisor On-call
3. Report discrepancies in an Scom via email to the Program Manager and Nurse for follow up.
4. Complete the appropriate documentation on the MAR.
vi. Within 24 hours, the Program Manager or Manager On-call (weekends only) will follow up on reported items and communicate via email to the CLA team, CLA Program Director and Director of Clinical Services.
b. Program Audits
i. Weekly medication audits will be conducted by members of CLA management team to ensure compliance.
1. The Residential Manager will complete an audit every Thursday
2. The House Supervisor will complete an audit every Tuesday
3. The Nurse will complete an audit once per week of each CLA on their caseload.
ii. The designated staff will:
1. Utilize the Program Audit Medication Checklist to conduct their audit
2. Report discrepancies identified in the medication audit via scom to the Program Manager and nurse for follow up.
3. Sign the back of the MAR in the notes section that they completed a MAR audit with the date completed.
iii. Within 24 hours, the Program Manager will follow up on reported items and communicate via email to the CLA team, CLA Program Director and Director of Clinical Services.
iv. Submit weekly audits to the CLA Administrative Assistant along with the Controlled Substance Count Record each week.
v. Data will be reviewed monthly in the CLA medication review meeting. |
11/04/2022
| Implemented |
| 6400.167(a)(1) | Individual 2's MAR is signed on 4/1/22 indicating their Divalproex Sodium 125 mg was administered, but the pills remained in the blister pack. | Medication errors include the following: Failure to administer a medication. | Medication Reviews and Audits
a. Overnight Medication Checks - DSP
i. Staff in each CLA shall conduct daily medication checks for each individual during the overnight shift.
ii. The DSP will utilize the Overnight Medication Checklist to conduct their review
iii. Program Managers will ensure that shift assignments are completed and posted for staff on each shift; with medication inspection identified among priority tasks on the assignment sheet. If the overnight staff is not medication administration certified, the Program Manager will assign the responsibility to a first shift staff or 2nd shift staff that is medication administration certified.
iv. Upon reporting on duty, staff (DSP) will review the shift assignment and identify staff assigned to inspect medications.
v. Assigned staff will:
1. Complete the checklist and sign and date it.
2. Report discrepancies identified in the medication checklist process to the Supervisor On-call
3. Report discrepancies in an Scom via email to the Program Manager and Nurse for follow up.
4. Complete the appropriate documentation on the MAR.
vi. Within 24 hours, the Program Manager or Manager On-call (weekends only) will follow up on reported items and communicate via email to the CLA team, CLA Program Director and Director of Clinical Services.
b. Program Audits
i. Weekly medication audits will be conducted by members of CLA management team to ensure compliance.
1. The Residential Manager will complete an audit every Thursday
2. The House Supervisor will complete an audit every Tuesday
3. The Nurse will complete an audit once per week of each CLA on their caseload.
ii. The designated staff will:
1. Utilize the Program Audit Medication Checklist to conduct their audit
2. Report discrepancies identified in the medication audit via scom to the Program Manager and nurse for follow up.
3. Sign the back of the MAR in the notes section that they completed a MAR audit with the date completed.
iii. Within 24 hours, the Program Manager will follow up on reported items and communicate via email to the CLA team, CLA Program Director and Director of Clinical Services.
iv. Submit weekly audits to the CLA Administrative Assistant along with the Controlled Substance Count Record each week. |
11/04/2022
| Implemented |