| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.144 | On 7/22/22 Individual #1's physician referred the individual to an Ophthalmologist due to the individual's corneal abrasion not healing completely after a few interventions. On 7/25/22 direct care staff took a telephone message from Individual #1's family physician, reporting that a referral was made, and the Ophthalmologist office would call in a week to schedule an appointment. The home did not receive communications from an Ophthalmologist. The home did not contact the individual's ordering physician until 9/2/22 to report that they never received communication from an Ophthalmologist. The home did not attempt to contact the Ophthalmologist office until 9/22/22, the last day of the annual inspection.
Individual #1's 9/17/22 hospital discharge summary includes a diagnosis of laceration of left side of back and metal foreign body in abdomen. There were further instructions to follow up with the individual's family physician to recheck the individuals blood pressure, as it was elevated. The hospital completed a chest X-ray with findings of mild hypo inflation with mild bibasilar opacities, possibly atelectasis, advised a follow-up to exclude infiltrates and pneumonia, reported mild enlargement cardiac silhouette, scattered degenerative changes in the spine, mild scoliosis, and metallic density overlying the upper abdomen, uncertain etiology. The hospital reports there is a similar appearing metallic density on the prior radiograph in the upper abdomen. During the 9/21/22 onsite inspection, direct care staff at the home and overseeing the individual's care were unaware of the hospital discharge instructions, diagnosis, and reports. The home's monthly health records for Individual #1 do not indicate that the home contacted the individual's primary care physician (pcp) for follow up for the laceration, metal foreign body in abdomen, high blood pressure, or reasons indicated on the chest X-ray report listed above. The home did contact with the pcp to inform them of the documented diagnosis of a metal foreign body in abdomen after this was discovered onsite on 9/21/22.
Staff person #5 reports Individual #1 has been ordered to complete at home physical therapy exercises due to the individual's unsteady gait. Since the previous inspection in November 2021, until 6/15/22 when the individual's physician discontinued these physical therapy exercises, there is no documentation of the individual completing exercises at home or any refusals. | 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.
| Retraining of all staff within the program of the new requirement, which is to schedule any follow up appointment within 24 hours |
10/10/2022
| Implemented |
| 6400.34(a) | The home has informed Individual #1 and their legal guardian of some regulatory individual's rights twice per year. The review of the individual's rights did not include a review of regulatory rights 6400.31(a)-(g), 32(r)(4) and (5), 32(v), and 33(a)-(b). | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | DOS and ADOS ensured that all regulations were on the form and also modified the form to include a section to document that the individual's rights were reviewed with the individual and for those individuals with legal guardians, with their legal guardians.
The update form was reviewed with all individuals in the residential program. |
10/10/2022
| Implemented |
| 6400.165(c) | On 6/26/22 Individual #1's physician ordered Erythromycin to be administered at 8am, 12noon, and 8pm for 5 days. The current written script sent to the pharmacy indicated the medication should be administered in the morning, at noon and in the evening. The pharmacy label printed by the pharmacy indicated to administer the medication at 8am, 2pm, and 8pm. The home administered the medication at 8am, 2pm, and 8pm, and not at 12noon. The home never obtained a change in written order from the prescribing physician, or attempted to contact the prescribing physician to report the change in time of administration on the pharmacy label compared to the written order. | A prescription medication shall be administered as prescribed. | The DOS wrote letters to the pharmacies that is utilized by our agency explaining the regulation. The letter states that if the original script is changed, that the prescribing physician must be contacted to approve the changes and to provide us with a new written order.
All staff in the program were retrained on the regulation and the process of ensuring medication is administered as prescribed. |
10/10/2022
| Implemented |
| 6400.165(e) | REPEAT from 11/8/21 annual inspection: On 2/17/22 Individual #1's physician ordered Lanolin ointment daily and discontinued the use of Aquaphor ointment on the individual's hands. On 2/18/22 a pharmacy technician reported to direct support staff of the home, the individual's prescribed lanolin ointment was missing from order and will not be available until 2/21/22. The pharmacy technician recommended the home continue using Aquaphor ointment until lanolin arrives. The home did not contact Individual #1's prescribing physician to confirm the change or obtain written orders from the prescriber of the change. The home staff followed verbal orders from the pharmacy technician. The verbal orders were provided to a non-medically certified home staff by a pharmacy technician. | Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received. | All staff in the program were retrained on the regulation and the process of ensuring any changes to medication is made by the prescribing physician and that a copy of the changes is in writing to update our records.
Staff have been retrained on the proper steps to take in the event that a medication is not able to be obtained from the pharmacy.
Staff have been retrained on the proper protocol to follow when a medication is discontinued, and the replacement medication is not available.
Staff have been retrained on the proper protocol and who can take verbal orders (only RN and LPN) |
10/10/2022
| Implemented |
| 6400.166(a)(15) | On 6/15/22 Individual #1 was prescribed Augmentin 875mg, every 12 hours, take medication with food, for five days due to a bite wound they sustained. The individual's June 15th-20th, 2022 medication administration records (mars) do not indicate the special precaution to administer the medication with food. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Special precautions, if applicable. | All staff in the program were retrained on the regulation and the process of ensuring any special precautions are clearly documented on the MAR. |
10/10/2022
| Implemented |
| 6400.166(b) | On 7/3/22 Staff person #1 recorded on Individual #1's July 2022 medication administration record (mar) that they were changing paperwork on 6/30/22 and signed the individual's mar for administering Head and Shoulders shampoo, Lantiseptic ointment, and gold bond medicated powder to the individual at 6pm and 8pm on 7/1/22. Staff person #1 pre-signed the individual's mar almost a day prior to administration of the ordered shampoo, ointment, and powder and was not the staff to administer said medication on 7/1/22.
Staff person #2 initialed as administering Fluticasone nasal spray to Individual #1 at 8am on 8/22/22. However, they did not administer the medication. Staff person #3 recorded that on 8/22/22 at 8am, they were unable to record their name in the location designated for administration of Fluticasone on 8/22/22 as another staff's signature was already in the designated location.
Staff person #4 administered Gold Bond medicated body at 8 am on 8/14/22 but did not record this information until 8/19/22. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | All staff in the program were retrained on the regulation and the process of ensuring all required information is clearly documented on the MAR.
Updated the internal ¿cheat sheet¿ that was created to ensure that staff have an example of proper documentation. |
10/10/2022
| Implemented |
| 6400.186 | Individual #1's individual support plan (isp) states they are prescribed as needed Desitin and A&D ointment creams for redness or irritation due to their diagnosis of incontinence. Neither ointment was available at the home during the 9/21/22 inspection. | The home shall implement the individual plan, including revisions. | For this specific area of non-compliance, these items were purchased to keep at the home, although the items were present at the time of inspection, just not kept in the individual's medication box.
All staff were retrained on this regulation and the importance of ensuring that all items listed in the ISP are present at the group home and are available for use at all times. |
10/10/2022
| Implemented |