Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.62(d) | Poisonous materials are not kept separate from food. Four bottles of juice were stored in the closet in the living room on a shelf with cleaning supplies. | Poisonous materials shall be kept separate from food, food preparation surfaces and dining surfaces. | Staff was retrained on 4/5/24 on the utmost importance of storing food items separately from poisons. There will also be ongoing training.to ensure there is not a reoccurrence. |
04/05/2024
| Implemented |
6400.144 | Health services including pharmaceutical are not provided. Individual #1 is prescribed over the counter, pro nata medications including Tylenol, Robitussin, Alegra, Tums, Colace, Imodium, Preparation H, Hydrocortisone cream, and Neosporin. These medications are not available in the home. | 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.
| Updated OTC, pro nata list is with the PCP for reviewing and approval. This will be forwarded to the pharmacy by 4/22/24. The Pharmacy will provide the medications and create a medication record. Medication record will be utilized to record administrations.. |
04/18/2024
| Implemented |
6400.165(c) | Prescription medications are not administered as prescribed. Individual #1 is prescribed Melatonin 5mg and Lamictal 25mg at 8PM. Medications packets dated 4/2/24 containing medications for this date were located in Individual #1's medication box. The Medication Administration Record initialed indicating that the medications were administered on 4/2/24. Individual #1 is prescribed Escitalopram 10mg at 8am. A medication packet dated 4/4/24 containing medications for this date were located in Individual #1's medication box. The Medication Administration Record initialed indicating that the medications were administered on 4/4/24. Individual #1 is prescribed Mirtazapine 15mg and Perphenazine 8mg at 8PM. A medication packet dated 3/20/24 containing medications for this date were located in Individual #1's medication box. The Medication Administration Record initialed indicating that the medications were administered on 3/20/24. | A prescription medication shall be administered as prescribed. | On 4/6/24 staff was retrained on proper medication administration procedures as per DHS guidelines |
04/06/2024
| Implemented |
6400.166(b) | Individual #1 is prescribed over the counter, pro nata medications including Tylenol, Robitussin, Alegra, Tums, Colace, Imodium, Preparation H, Hydrocortisone cream, and Neosporin. These medications and dosing instructions are not recorded on the medication administration record. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Updated OTC, pro nata list is with the PCP for reviewing and approval. This will be forwarded to the pharmacy by 4/22/24. The Pharmacy will provide the medications and create a medication record. Medication record will be utilized to record administrations.. |
04/18/2024
| Implemented |
6400.185(1) | Individual #1's Individual Service Plan (ISP) does not contain revisions including the Individuals ability to manage money. Individual #1's annual assessment dated 3/8/24 states "Individual #1 recognizes money as a medium exchange and has cash in the individual's possession without losing it." Individual #1's ISP states "Individual #1 is unable to complete transactions without supervision and does not possess any concept of money thus would be easily exploited without someone to assist with money management. Wakefield currently serves as rep payee." Individual #1 is provided between $10-50 in spending money that the individual maintains on their person. The information contained in Individual #1's ISP indicates that Individual #1 is unable to maintain any amount of money. | The individual plan, including revisions, must include the following: The individual's strengths, functional abilities and service needs. | The ISP has been revised to include the individuals' strengths functional ability and service needs as illustrated below.
The Individual understands money as a medium of exchange. She is also able to identify one dollar, five-dollar, ten dollar and twenty-dollar bills. Individual is unable to complete transactions on her own and requires supervision due to limited concept of money. While she is able to identify money , the team believes that individual would be at risk of financial exploitation thus she is always supervised when making purchases up to $50 to eliminate risk. Individual will stand in line with staff and wait for her receipts. Individual is able to carry up to $20 in her possession without losing it. Wakefield Cottage currently serves as her Rep payee. |
04/22/2024
| Implemented |