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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.50(a) | · Staff #4 received training on Individual Support Plans on 10/26/23. This training record does not document the length of training.
· Staff #5 received training on Individual Support Plans on 12/2/23 and 12/21/23. These training records do not document the length of training.
· Staff #6 received training on Individual Support Plans on 10/12/23. This training record does not document the length of training. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | On 2/7/24, it was discovered that the length of training was not documented on ISP training records on 10/12/23, 10/26/23, 12/2/23, and 12/21/23. On 2/12/24, the Director of Employee Development completed a training with the agency trainers and the program specialist (Attachment 1). The training was on regulation 6400.50(a) which states that records of orientation and training, including training source, content, dates, length of training, copies of certificates received, and staff persons attending shall be kept. The plan of correction was also reviewed, which is that all training including ISPs, BSPs, RPPs will include the length of the training documented on the training record. On 2/15/24, ISP trainings were conducted by the agency trainer. The training records show that the length of training was documented (Attachment 2). |
02/22/2024
| Implemented |
| 6400.166(a)(11) | · Individual #1 was prescribed Lurasidone 80mg tablet on 11/22/23. November 2023, December 2023, and January 2024 MARs do not list the diagnosis or purpose of this medication.
· Individual #1 is prescribed Saline Mist 0.65% Nose Spray, use 1 spray in each nostril 4 times daily. This medication was crossed out and rewritten on the December 2023 on 12/17/23. The rewritten medication does not include the diagnosis or purpose.
· Individual #1 is prescribed Buspirone 5mg Tablet, take one tablet by mouth twice daily. This medication was discontinued on 12/20/23 and rewritten on the December 2023 MAR. The rewritten medication does not include the diagnosis or purpose. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | On 2/6/24, it was discovered that there was no reason or diagnosis on the individual¿s medication record for November 2023- January 2024 for Lurasidone, Saline Mist, and Buspirone. On 2/8/24, the manager of the home completed a home review, which included a medication review (Attachment 8). It was noted that there was a reason or diagnosis for all medications on the medication record. On 2/15/24, the Chief of Supports and Services completed a training with the management team and this regulation. (Attachment 5). The reason or diagnosis for the medications was added to the medication record for February. A review of the medication record was completed by the VP of Quality Management on 2/22/24 showing that all medications had a reason or diagnosis (Attachment 9). |
02/22/2024
| Implemented |
| 6400.166(a)(13) | · Individual #1 is prescribed Saline Mist 0.65% Nose Spray, use 1 spray in each nostril 4 times daily. This is to be done at 8am, 12pm, 4pm, and 8pm. There is no documentation 11/14/23 at 12pm, 12/25/23 at 8pm.
· Individual #1 is prescribed Naproxen 500mg tablet, 1 tablet by mouth in the evening with food for leg pain. There is no documentation whether this medication was administered on 11/27/23.
· Individual #1 is prescribed Bengay Ultra Strength Cream, apply to the affected area once daily at bedtime. There is no documentation whether this medication was administered on 12/27/24. | 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. | On 2/6/24, it was discovered that there were no initials on the individual¿s medication record for Saline Mist on 11/14/23 and 12/25/23, Naproxen on 11/27/23, and Bengay on 12/27/23. On 2/8/24, the manager of the home completed a home review, including a medication review (Attachment 8). It was noted that there weren¿t any documentation errors on the medication record, which would include any medications not being initialed as being given. On 2/15/24, the Chief of Supports and Services completed a training with the management team and this regulation (Attachment 5). A review of the medication record was completed by the VP of Quality Management on 2/22/24 showing that all medication administrations had been initialed (Attachment 9). |
02/22/2024
| Implemented |
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