| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | The first aid kit contents did not include a thermometer. | (b) 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.
| How we fixed the immediate problem: A thermometer was purchased on 1/09/14 and replaced in the First Aid Kit.
How we will make sure the problem does not happen again:
The Home Coordinator/Supervisor is responsible for completing the Monthly Residential Site Checklist and submitting to the Team Coordinator or Program Director for review each month. Under the First Aid Kit heading of the checklist, a thermometer is listed as a requirement of the First Aid Kit.
|
01/09/2014
| Implemented |
| 6400.164(a) | Staff person #1 did not include their full signature on medication log sheet. | (a) A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication.
| How we fixed the immediate problem: The staff person signed his full name on the MAR. The other MARs at this service location were also reviewed and were determined to be in compliance with full names of all staff administering medications.
How we will make sure the problem does not happen again: The Home Coordinator/Supervisor checks MARs at least three (3) times a week in order to ensure accurate medication administration and documentation (staff initials and signatures). The Home Coordinator/Supervisor documents his/her findings on the Medication Administration Review Checklist, which was updated on 3/19/14 to include review of full names for staff signatures. If a medication documentation or administration error is discovered, an incident report is written and necessary follow-up will occur. The MAR reviews are submitted to the Team Coordinator or Program Director for review. Any corrections are addressed immediately. |
01/09/2014
| Implemented |
| 6400.183(5) | Individual #1's file record did not include a copy of the current Social Emotional Environment Plan. | (5) A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness.
| How we fixed the immediate problem: RA completed a SEEP on 1/09/14.
How we will make sure the problem does not happen again: RA updates the SEEP annually based on progress notes from the treatment/service plan. RA files progress notes received from the Director of Clinical and Behavioral Services. In addition, the Director of Service Coordination conducts quarterly audits of three (3) participant records from each Program Specialist¿s caseload. |
01/09/2014
| Implemented |