| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | The hot water measured in the tub was (130.0* F) | Hot water temperatures in bathtubs and showers may not exceed 120°F. | *The individual living in this home is the only person and per her assessment, can regulate water temperatures. On 11/23/21, Service Director encouraged individual to use shower only when staff were on shift to ensure that if she needed assistance with regulating water temperature, they would be available. As individual resides in an apartment complex, Service Director placed a call to the Leasing Office/Maintenance Department requesting follow up to this issue.
*On 12/17/21, CSW along with the individual again contacted the Maintenance Department to determine if the water temperature could be adjusted in her individual apartment to meet regulation standards. Maintenance visited the site on 12/17/21 and determined that they could not adjust the water temperature in her unit only and to do so would impact the other tenants in the complex. They provided instruction on how she should regulate the water for safety. Individual reported that she is aware/comfortable with adjusting water as needed.
*Service Director contacted outside plumber to install temperature regulator on individual¿s bathtub/shower waterline and work is scheduled to be completed by 2/5/2022.
(Agency will send completed work order to licensing) |
02/05/2022
| Implemented |
| 6400.141(c)(14) | Information pertinent to diagnoses in case of emergency was left blank on individual #1's physical dated 8/13/2021 | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | *VIA Nurse Consultant reached out to individuals' PCP office to obtain the missing information so that the form is now completed as required. |
01/24/2022
| Implemented |
| 6400.144 | Individual #2's Medication(s) VALSARTAN 80mg and FAMOTIDINE 20mg on MAR, could not be located on site at time of inspection. | 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 individual, as indicated in her assessment, can self-administer her medication and at the time of the inspection, retrieved the medication from her room and placed it in her medication box along with her other medications.
*Service Director identified a CSW Point Person for each team who is tasked with the responsibility of ensuring that medications are current and available utilizing a newly created Medication Check Record |
02/01/2022
| Implemented |
| 6400.181(e)(5) | The assessment dated 8/9/2021 did not adequately discuss the level of assistance needed for individual #1 to self-administer medications. The assessment stated agency delivers medications from pharmacy but does not discuss the level of assistance needed to administer the individual's medications. | The assessment must include the following information: The individual's ability to self-administer medications. | *PS revised the assessment to expand upon the details associated with an individuals¿ ability to self-medicate per regulatory standards. This individuals¿ assessment was revised on 1/25/2022 to reflect her current ability and support needs. |
01/25/2022
| Implemented |
| 6400.165(c) | Individual #2's medication FLONASE ALLERGY RELIEF 50mg, medication expired 06/2001 | A prescription medication shall be administered as prescribed. | *Associate Director immediately removed the expired medications from the individuals¿ medication box, reordered any needed PRN medications and confirmed that all medications were current.
*Service Director identified a CSW Point Person for each team who is tasked with the responsibility of ensuring that medications are current and available utilizing a newly created Medication Check Record |
02/01/2022
| Implemented |
| 6400.167(c) | There was several medications located in a plastic tote which was documented as contaminated, the date on the plastic bag was 8/2021, these medication were not disposed of correctly. | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | *As this individual has been assessed to be able to self-medicate, and failure to properly dispose of contaminated medications is not considered a medication error or a reportable incident; however, this individual has been taught by the Associate Service Director the proper way to dispose of meds that are contaminated to ensure that they are no longer present in the home.
*Service Director identified a CSW Point Person for each team who is tasked with the responsibility of ensuring that medications are current and available utilizing a newly created Medication Check Record |
02/01/2022
| Implemented |