| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(6) | Is the person free from communicable diseases? Is not checked yes or no on individual 1 physical. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | JEVS is implementing a system for reviewing medical examination forms to make sure they are complete and that all parts of the forms are filled out correctly. In this case, individual 1 has a history of positive PPD but negative chest x-rays. JEVS should have noticed that the physical form was not filled out completely and referred to the x-ray history. |
08/01/2023
| Implemented |
| 6400.141(c)(10) | individual 1 physical did not complete TB testing; it was not in the binder. Staff informed individual 1 regularly tests positive so individual 1 gets a chest x-ray. On 9/27/22 physical says ordered, but still was not presented that x-ray nor old ones. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | JEVS is implementing a system for reviewing medical examination forms to make sure they are complete and that all parts of the forms are filled out correctly. In this case, individual 1 has a history of positive PPD but negative chest x-rays. JEVS should have noticed that the physical form was not filled out completely and referred to the x-ray history. |
08/01/2023
| Implemented |
| 6400.144 | Medication FLOVENT 50MG is not located in the individual #1's medication box, the staff is signing on MAR (electronic) that medication is being administered (from 06/01/23 thru 06/07/23).
Medication VITAMIN B3 is listed on the individual #2's MAR (electronic) but medication is not in the home, staff is signing that the medication is being administered. | 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.
| The Flovent was given at an urgent care in January 2023 for an illness. It was not supposed to be given long term and should have been removed from the MAR. That has now been corrected. The vitamin B3 was on the MAR in error and has since been removed, The individual is getting the correct medications |
08/01/2023
| Implemented |
| 6400.163(d) | The medication container is not kept locked the key is tied to the medication box and the lock is not closed.
Medications were not double locked for the individuals in the home who take supraoptic medications. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | This has been corrected. They keys are kept separate from the medication boxes and the closet. They are no longer attached to the boxes. The controlled substances are double locked as requires |
08/01/2023
| Implemented |
| 6400.165(b) | PRN medication SILTUSSIN 100MG and TRIPLE ANTIBOTIC OINTMENT is listed on individual #1s MAR but not present in the medication box.
Medication PHARBETOL 325MG and CALCUIM ANTACID 500mg both listed on the MAR but not in the individual #2's med box. | A prescription order shall be kept current. | The Siltussin 100mg and Pharbetol 325mg and triple antibiotic ointment have since been ordered and delivered to the home. The Calcium antacid 500mg is removed from the MAR. It is not to be given any longer. |
08/01/2023
| Implemented |