|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.33(f) | Individual #1 and #2 do not have access to their closets due to it being locked. | An individual has the right to receive, purchase, have and use personal property. | 15. On 5/18/2019, our maintenance changed the lock on the closet door giving access to individual#1 and #2. Moving forward, the Residential manager will ensure that individuals have access to all area of the home; however, with their health and safety in mind. The COO and CEO will be responsible for ensuring implementation. Attachment#13 |
07/04/2019
| Implemented |
| 6400.66 | The Light over the front door exit was not working and the light over the rear door exit was not working | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| 13. On 5/18/19, our maintenance repaired the light over the front door exit and rear door exit, and both are now working. In the future, the Residential manager will complete work orders to initial repairs and replacement of damaged or missing furniture to prevent any future re-occurrences. Attachment#12 |
07/04/2019
| Implemented |
| 6400.67(a) | Individual # 2's dresser drawers were broken and off there tracks. | Floors, walls, ceilings and other surfaces shall be in good repair. | 12. On 5/18/19, we bought a brand-new dresser and replaced the broken chest in individual# two bedrooms. In the future, the Residential manager will complete work orders to initial repairs and replacement of damaged or missing furniture to prevent any future re-occurrences. Attachment#11 |
07/04/2019
| Implemented |
| 6400.67(a) | The Blinds in the play room were broken. | Floors, walls, ceilings and other surfaces shall be in good repair. | 11. As of 5/18/19, our maintenance person replaced the broken blinds located in the rec-room. In the future, the Residential manager will complete work orders to initial repairs and replacement of broken or missing furniture to prevent any future re-occurrences. Attachment#10 |
07/04/2019
| Implemented |
| 6400.76(a) | The Kitchen table was not sturdy and tilted when it was touched | Furniture and equipment shall be nonhazardous, clean and sturdy. | 10. On 5/18/2019, our maintenance person secured the loosed bolt on the kitchen table. In the future, the Residential manager will complete work orders to initial repairs and replacement of broken or missing furniture to prevent any future re-occurrences. |
07/04/2019
| Implemented |
| 6400.76(c) | The Dining room table is a small square foldable card table for the three individual's living in the home. | Furniture shall be comfortable and home-like. | 9. On 5/18/2019, Halia management (CEO)completed the purchasing of a new dining room set (1 table and four chairs). Halia management (CEO)will supervise the maintenance and ensure that sufficient of all furniture is available in all of the homes. In the future, the Residential manager will complete work order to initial repairs and replacement of broken or missing furniture to prevent any future re-occurrences. Attachment#8 |
07/04/2019
| Implemented |
| 6400.76(d) | The Kitchen table had two chairs, which does not accommodate all three individuals in the home. | In homes serving eight or fewer individuals, there shall be a sufficient amount of living and family room furniture to seat all individuals at the same time. | 9. On 5/18/2019, Halia management (CEO)completed the purchasing of a new dining room set (1 table and four chairs). Halia management (CEO)will supervise the maintenance and ensure that sufficient of all furniture is available in all of the homes. In the future, the Residential manager will complete work order to initial repairs and replacement of broken or missing furniture to prevent any future re-occurrences. Attachment#8 |
07/04/2019
| Implemented |
| 6400.77(b) | The First aid kit did include tweezer, scissor or a thermometer. | 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. | 8. On 5/17/2019, Halia's CEO and Residential Manager double-checked and provided all homes with new first aid kit that contained the all required items. The residential manager is responsible for ensuring continuity of supply of first aid kits and materials. |
07/04/2019
| Implemented |
| 6400.83(a) | During the inspection there were three (one white, one blue and one multi-color) plates in the kitchen to use for daily meals for three (3) individuals. | A home shall have a kitchen area with a refrigerator, sink, cooking equipment and cabinets for storage. | 7. On 5/17/2019, Halia completed purchased and supplied matching utensils, cooking equipment, cups and plates to all the homes guaranteeing adequate provisions to assist all individuals in eating comfortably in their home. To prevent a re-occurrence of this violation, Halia's CEO will continue to oversee all sites to ensure that adequate provision is available for use at all times.
attachment#6 |
07/04/2019
| Implemented |
| 6400.141(a) | Individual #1's Dental exam was not completed annually, 6/27/18 was last dental exam. No dental exam was found for the year 2017. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | 22. June 2019, the Residential manager, (responsible for following up on dental appointment ) made sure that Individual#1 dental appointment was completed . Moving forward, COO/PS will conduct bi-annual self-inspection of all individuals program and medical books to prevent the occurrence of this non-compliance area. Attachment#4 |
07/04/2019
| Implemented |
| 6400.144 | Individual #1 Medical Administration Record (MAR) documents staff has been administrating Zyprexa 20 MG at 8pm(Bedtime) for the month of May 2019, but the medication was not onsite. The House Manger searched the home and found an old empty blister pack. | 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.
| 6. 6400.144- Upon discovery of the missing meds (Zyprexa 20mg) the residential manager urgently placed an order for a replacement and received the (Zyprexa 20mg) medication on the same day (5/15/2019). Individual#1 did receive his medication on time, and there was no gap or break in his med's administration. To prevent future occurrences of this oversight, the Residential Manager, Halia meds administration trainer and staff will do periodic meds checks/review via Halia's Medication Q/A Checklist. Attachment#5 |
07/04/2019
| Implemented |
| 6400.164(a) | Individual #1 medication label: Basaglar 100 unit/ML inject subcutaneous 14 units at bedtime. Individual #1's Medical Administration Record (MAR) is written as: Basaglar 100 units/ML Inject Subcutaneous 12 units at bedtime. The House Manager confirms staff is providing 12 injectable units per dose daily. The medication label and MAR do not match, and it could not be determine if the individual received the appropriate dose of medication. | 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. | 5. 6400.164- Regarding the Basaglar 100 unit/ML, our record shows that individual#(1) has been receiving 12 injectable units per dose since November when his endocrinologist made a reduction from 14 units to 12 units. However, during the inspection, the inspector discovered the older empty container, which label indicates 14 injectable units but the current (actual 12unit container label of Basaglar 100 unit/ML) was also in the box. On 5/15/19, we immediately discarded the (14 units label) from the meds box. Moving forward, Halia's Residential Manager will ensure to dispose of all previously used containers appropriately to prevent future occurrences. Attachment#5 |
07/04/2019
| Implemented |
| 6400.171 | In the microwave was breakfast food and a fork left from earlier that day. | Food shall be protected from contamination while being stored, prepared, transported and served.
| 4. Halia recognized that leaving Food open and leaving metal in the microwave is dangerous, and a health and safety concern and has retrained all staff to refrain from such mistake. Our Staff and Residential Manager are responsible for ensuring that all Food shall be protected from contamination while being stored, prepared, transported, and served. Attachment#3 |
07/04/2019
| Implemented |
| 6400.171 | An open container of yogurt was found in the refrigerator. | Food shall be protected from contamination while being stored, prepared, transported and served.
| 3. Halia recognizes that leaving Food open and leaving metal in the microwave is dangerous, and it is a health and safety concern. Management has revised its process for food safety and advised all staff to refrain from such a mistake. The PS and RM are responsible for ensuring that all Food shall be protected from contamination while being stored, prepared, transported, and served. The policy procedure is posted on the refrigerator in all homes to prevent future violation. Attachment#3 |
07/04/2019
| Implemented |
| 6400.174 | Individual #1 was eating yogart for lunch during inspection and staff later provided a paper plate with potato salad. Staff confirm the non verbal individual requested yogart and potato salad for lunch. | At least one meal each day shall contain at least one item from the dairy, protein, fruits and vegetables and grain food groups, unless otherwise recommended in writing by a licensed physician for individuals.
| 2. Halia's Residential Manager is responsible and will conduct on-going monitoring of all of the sites, and the staff members adhere to the weekly meal plan that posted in all homes. To prevent future occurrences, the CEO oversees this process to make sure that at least one meal each day shall contain at least one item from the dairy, protein, fruits and vegetables and grain food groups unless otherwise recommended in writing by a licensed physician for individuals. Attachment#2 |
07/04/2019
| Implemented |
| 6400.181(f) | There was No documentation found in individual #1's record showing that the Annual assessment was sent to Supports coordinator or team members at least 30 days prior to the Individual Support Plan (ISP) meeting. | (f) The program specialist shall provide the assessment to the SC, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP).
| 1. COO reviewed with the PS her job description regarding process completing and mailing out annual assessments to SCs. The PS received training on 6/17/19 on the job responsibility. The PS under supervision of COO is responsible for ensuring the implementation of this process. Attachment#1 |
07/04/2019
| Implemented |
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(3) | REPEAT VIOLATION 02/26/2016
A receipt for the amount of $46.18 and $311.04 was missing from Individual # 2's financial records. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | The amount of 46.18 dollars indicated on violation constitute co-payment for prescription with Willits Pharmacy. (see attachment)Accordingly, the residential manager, and Financial Officer will manage the individual accounts. Moving forward, the non-compliance issues will be alleviated by making direct payment to willits from the individual account so that transaction is stipulated on bank statement. The residential manager and financial officer will oversee implementation. On 02/26/2016 the amount 311.04 dollars was deducted from Individual # 2's account for room and board payment. This deduction was based on SSI deposits of 216.00 for 01/20/2016 and 216.00 for 02/03/2016 which amount to 432.00. Our financial office transferred 72 percent (representing room and board) of that amount to Halia account which amounted to 311.04. However, out internal audit revealed that individual # 2 had already paid room and board for January and February, and further room and board deduction from the account was against the regulation. This amount was due to be reimbursed to Individual # 2 monthly agreed upon room and board payment is 351.84. During the month of Amrch, a deducted 155.52 for room and board leaving a balance of 196.32 individual # 2 owed. On 04/21/2016 114.72 was credit to Individual # 2's account to make for the 311.04 error. Moving forward, a more comprehensive accounting reporting process will be utilized to prevent this type of confusion with the individual account, this alleviating reoccurrence of non-compliance. General oversight: residential manager and financial officer. |
01/06/2017
| Implemented |
| 6400.46(f) | Staff # 2's fire safety training dated 10/05/2016 was not completed by a fire safety expert. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | Oversight: Administrator and CEO. Halia has scheduled an instructor led (expert) fire safety training in the month February2017, and staff#2 is placed on list to attend this training. Moving forward, the (AA) will utilize employee checklist to avoid reoccurrence of this non-compliance. |
01/04/2017
| Implemented |
| 6400.46(g) | Staff # 2's fire safety training dated 10/10/2016 was completed by another residential provider and not specific to residential program under Halia Homes. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (f). | Oversight: Administrator and CEO. Halia has scheduled an instructor led (expert) fire safety training in the month February 2017, and staff#2 is placed on list to attend this training. Moving forward, the (AA) will utilize employee checklist to avoid reoccurrence of this non-compliance. |
01/06/2017
| Implemented |
| 6400.62(a) | REPEAT VIOLATION 02/26/2016
Pine sol multi-surface cleaner, price rite ultra bleach and Mr. Clean multi-purpose cleaner which indicated to contact poison control if ingested were found unlocked on the shelf above the washer and dryer. | Poisonous materials shall be kept locked or made inaccessible to individuals. | As of 12/6/2016, all poisonous materials were stored and kept locked away from the individuals. To prevent the reoccurrences , the residential manager or designee will have oversight ensuring the staff follow through in keeping poisonous materials locked away.(the executive director or designee will conduct weekly site inspections to ensure continued compliance with this regulation. Site inspections shall be documented DS 02.15.17) |
01/25/2017
| Implemented |
| 6400.64(a) | There was a two inch brown colored stain consistent with feces on the toilet seat located in the upstairs bathroom. | Clean and sanitary conditions shall be maintained in the home. | In order to keep a clean and sanitary conditions of the bathroom, Halia's contracted a maintenance worker installed a new toilet seat in the upstairs bathroom. Moving forward, the maintenance contractor working with the residential manager or designee will report all structural problems for immediate repairs. |
01/25/2017
| Implemented |
| 6400.66 | The lighting in the living room was not adequate.
The light was inoperable in Individual # 3's bedroom.
A light bulb was missing from the fixture above the mirror in the bathroom. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| Halia management has installed more lighting in the living room area, replaced light bulb/fixtures. The repairs were completed on 12/15/16 by maintenance contractor. Moving forward, to prevent the reoccurrences of this violation, the residential manager or designee will report all structural problems for immediate repairs.(the executive director or designee will conduct weekly site inspections to ensure continued compliance with this regulation. Site inspections shall be documented DS 02.15.17) |
01/25/2017
| Implemented |
| 6400.67(a) | REPEAT VIOLATION 02/26/2016
There were two holes in the living room wall measuring approximately four inches in length.
There was a cracked section approximately three inches in length on the living room closet door.
There was a four inch hole similar to the size of a fist in the inside part of the living room closet door.
There were two, two inch cracks and an one inch circular hole near the top right side of the door located in the bathroom.
There is a crack on the frame around the back door window as well as five cracked or missing rectangles on the back door window frame.
There was a five inch crack in the upstairs closet door.
There is a split in the accordion style closet door located in Individual # 3's bedroom.
There is a cracked door stop and a three inch circular hole in the wall in Individual # 2's room.
There was a crack approximately eighteen inches in length on the right side and bottom of a door located in Individual # 2's bedroom.
There were approximately twenty small circular holes in the wall located in Individual # 2's bedroom.
There was a broken electrical outlet cover located in Individual # 3's bedroom.
There were multiple cracks and holes varying in size found in the accordion style closet door located in individual # 3's bedroom.
The top of the closet door in Individual # 3's bedroom is missing and being held in place by a small piece of the door.
There was an one inch hole and a two inch hole in the wall behind the door located in Individual # 3's bedroom.
The entire left side door frame is missing from a door located in Individual # 3's bedroom.
There was a five inch square piece missing from the wall located in the linen closet in Individual # 3's bedroom.
There was approximately a fifteen inch crack on the front part of the bedroom door located in Individual # 3's bedroom.
The bottom drawer on the bathroom sink cabinet fall out when pulled.
There is peeling paint on the ceiling above the shower in the upstairs bathroom.
There was a ten inch crack on the left side of the door frame located in Individual # 3's bedroom.
There are eleven tiles missing from the basement floor.
There are four broken tiles with missing pieces on the basement floor.
There are four holes approximately an inch in length located on the ceiling tiles in the basement.
There is a three inch hole in a ceiling tile located in the basement.
There is a four inch circular hole and a four inch rectangular hole in the basement wall located by the exit door.
The cover is missing from the electrical outlet located in the living room.
| Floors, walls, ceilings and other surfaces shall be in good repair. | Repairs work on all structural damages numerated in 6400.67(a) were completed as of 12/20/16. Moving forward, Halia¿s management has in place a periodic maintenance of all homes to prevent the reoccurrences of this violation, the residential manager or designee will report all structural problems for immediate repairs.(the executive director or designee will conduct weekly site inspections to ensure continued compliance with this regulation. Site inspections shall be documented DS 02.15.17) |
01/25/2017
| Implemented |
| 6400.67(b) | There is a missing piece on the bottom right corner of the light switch cover located in Individual # 2's bedroom.
A light switch in the bathroom is separating from the wall.
A light switch in the basement is separating from the wall.
A light switch in the kitchen is separating from the wall.
| Floors, walls, ceilings and other surfaces shall be free of hazards. | Repairs work on the light switch was completed on 12/15/16. Our maintenance contractor repaired the replaced the switch on 12/15/16. To prevent the reoccurrences of this violation, the residential manager or designee will report all structural problems for immediate repairs..(the executive director or designee will conduct weekly site inspections to ensure continued compliance with this regulation. Site inspections shall be documented DS 02.15.17) |
01/25/2017
| Implemented |
| 6400.76(a) | The legs on the dining room bench were loose and unstable.
The leg was missing from a wooden chair located on the back patio. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The repairs were completed on 12/15/16. Our maintenance contractor repaired the loose and unstable lags on the dining room bench on 12/15/16. To prevent the reoccurrences of this violation, the residential manager or designee will report all structural problems for immediate repairs..(the executive director or designee will conduct weekly site inspections to ensure continued compliance with this regulation. Site inspections shall be documented DS 02.15.17) |
01/25/2017
| Implemented |
| 6400.80(b) | There was a two foot plank missing from the wooden fence located in the backyard.
There are several jagged edges along the bottom on the fence located in the backyard.
There is rust on the entire shed located in the backyard. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | The repairs were completed on 12/15/16. In order to maintain individual safety, HALIA management change and installed a new steel fence located in the backyard. The residential manager or designee is responsible for all structural upkeep of all facilities..(the executive director or designee will conduct weekly site inspections to ensure continued compliance with this regulation. Site inspections shall be documented DS 02.15.17) |
01/25/2017
| Implemented |
| 6400.112(a) | There is a fire drill schedule documenting a date range and predetermined time for when a fire drill shall occur each month. | An unannounced fire drill shall be held at least once a month. | Fire drills are now executed on a unscheduled/unannounced random time, and continue to occur monthly. The Residential Manager or designee is responsible for the proper implementing of fire drills. |
01/25/2017
| Implemented |
| 6400.144 | REPEAT VIOLATION 02/26/16
Individual # 2 is prescribed Aristocort 0.1 % ointment PRN, triamcinolone ointment 0.1% PRN and atrovent 0.02% solution PRN and these medications were not in the home. | 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.
| As of 12/6/2016, Atrovent 0.02% solution was discontinued by the PCP and the Pharmacy was asked omit this medication from MAR. The pharmacy supplied Aristocort 0.1 % ointment PRN, triamcinolone ointment 0.1% . Moving forward, all MAR and medications are being reviewed weekly via the (see Attachment #1 ¿ Medication Q/A Checklist). The manager or designee will monitor and check all medications per the Q/A checklist. |
01/25/2017
| Implemented |
| 6400.151(b) | Staff # 3's physical examination dated 07/26/2016 was not dated by the physician. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Staff #3 was directed back to his physician and all correction to the staff physical was made. The Administrator, and Administrative assistant will conduct periodic check via (see Attachment#2 Employee file Checklist)(The executive director or designee will complete a record review of all staff within 30 days of receipt of this plan to ensure all physicals are signed by the physician. if a record if found to be out of compliance it will be corrected within 15 days. DS 02.15.17) |
01/25/2017
| Implemented |
| 6400.151(c)(3) | Staff # 3's physical examination dated 07/26/2016 did not document if the staff was free of communicable diseases | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | Staff #3 was directed back to his physician and all corrections to the staff physical were made. The Administrator, and Administrative assistant will conduct periodic check via (see Attachment#2 Employee file Checklist). Moving forward, a thorough review of all staff physical will be made by the AA.)(The executive director or designee will complete a record review of all staff within 30 days of receipt of this plan to ensure all physicals indicate whether a staff is free of communicable disease. if a record if found to be out of compliance it will be corrected within 15 days. DS 02.15.17) |
01/25/2017
| Implemented |
| 6400.162(a) | Individual # 2's medication administration record documented Benzoyl Pexiode PRN however the medication did not have a pharmaceutical label. | The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. | On 12/17/16, the pharmacy was contacted and the corrected pharmaceutical label is now in the home. All resident MARs and medications are being reviewed weekly via the (see Attachment #1 ¿ Medication Q/A Checklist) to prevent any discrepancies. The manager or designee will monitor for proper the administration of medication on a weekly basis. The manager did contact the pharmacy and necessary corrections and discrepancy was resolved. |
01/25/2017
| Implemented |
| 6400.164(a) | REPEAT VIOLATION 02/26/2016
Staff # 1 administered medication to Individual # 1 on 12/05/2016 and did not sign the medication administration record.
According to the pharmaceutical label, Individual # 1 is prescribed Colace 100 mg two times per day at 8:00AM and 8:00PM. The medication administration record for individual # 1 documents Colace 100 mg to be administration at 4:00PM and 8:00PM
| 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. | Staff#1 has since been re-assigned to another program where medication is not served pending training. Oversight supervision: Residential Manager, Agency Nurse, Staff, Program Specialist and Administrator. Halia has in place 2 checklists Attachment#2 (Employee file checklist) and (see Attachment #1 Medication Q/A Checklist). Which is being implemented by all staff, Residential Manager and Agency Nurse on weekly basis to avoid a reoccurrence of this violation. Action was taken to correct this oversight was completed as of 12/15/2016.
Regarding documentation discrepancy, On 12/17/16, the pharmacy was contacted and the corrected pharmaceutical label is now in the home. All resident MARs and medications are being reviewed weekly via the (see Attachment #1 ¿ Medication Q/A Checklist) to prevent any discrepancies. The manager or designee will monitor for proper the documentation of all medications on a weekly basis. The manager did contact the pharmacy and necessary corrections and discrepancy are resolved. |
01/25/2017
| Implemented |
| 6400.164(b) | Individual # 1's medication administration record was not initialed for the 8:00PM dose of Colace 100mg on 12/03/16 and 12/04/2016.
Individual # 2's medication administration record was not initialed for the 8:00PM does of Zyrtec 10mg on 12/01/2016
Individual # 2's medication administration record was not initialed for the 12:00AM does of Keflex 500 mg10mg on 12/04/2016. | The information specified in subsection (a) shall be logged immediately after each individual's dose of medication. | (MM), COO/Administrator, immediately on 12/7/16, the correction was made to the MAR reflecting medication administration. To prevent future occurrences, the Program Specialist, Residential Manager or designated management staff will conduct at least a daily review of MARs and medications to ensure compliance with related 6400 regulations. The MAR was corrected on 12/072016 and subsequent records are being updating with all Individual#1 medications. (daily reviews of MARS is being conducted for all individuals the agency serves. By using (see Attachment #1 Medication Q/A Checklist). The manager or designee monitors for proper administration of medication and documentation on a weekly basis. All staff are being in-service as to regulations concerning logging in initials immediately following administrating medications. |
01/25/2017
| Implemented |
| 6400.168(a) | REPEAT VIOLATION 02/26/2016
Staff # 1's initial medication administration training dated 05/14/2016 was invalid as the observations were not completed. Staff # 1 administered medication to Individual # 1 and Individual # 2 in November and December 2016. | In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. | Staff#1 has since been re-assigned to another program where medication is not served pending training. Oversight supervision: Residential Manager, Agency Nurse, Staff, Program Specialist and Administrator. Halia has in place 2 checklists Attachment#2 (Employee file checklist) and (see Attachment #1 Medication Q/A Checklist). Which is being implemented by all staff, Residential Manager and Agency Nurse on weekly basis to avoid a reoccurrence of this violation. Action was taken to correct this oversight was completed as of 12/15/2016. |
01/25/2017
| Implemented |
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|
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(1) | The provider is Individual # 2's representative payee and did not have a record of financial resources including withdrawals and deposits. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. | Administrator, Residential Manager, Financial Officer, CEO
A systematic financial tool (e.g.: balance sheet) indicating beginning and ending balances along with all credits and withdrawals. Halia will maintain all receipts of purchases made on behalf of the individuals that Halia is a representative payee.
Halia has contacted Advocacy Alliance to take over the responsibility of representative from Halia. [Halia will return the 1,482.93 dollars of undocumented withdraws (for which no receipt was provided)to Individual #2 by 9.30.2016. Additionally, Halia will enter the incident into EIM within 24 hours of receipt of this plan of correction DD 8.5.16]
|
04/30/2016
| Implemented |
| 6400.22(e)(3) | Individual # 2 needs assistance with managing money and the provider is the representative payee. the individual's record does not have receipts for purchases totally $15.00 or more. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | Administrator, Residential Manager, Financial Officer, CEO
A systematic financial tool (e.g.: balance sheet) indicating beginning and ending balances along with all credits and withdrawals. Halia will maintain all receipts of purchases made on behalf of the individuals that Halia is a representative payee.
Halia has contacted Advocacy Alliance to take over the responsibility of representative from Halia. [Halia will return the 1,482.93 dollars of undocumented withdraws (for which no receipt was provided)to Individual #2 by 9.30.2016. Additionally, Halia will enter the incident into EIM within 24 hours of receipt of this plan of correction DD 8.5.16]
|
04/30/2016
| Implemented |
| 6400.46(d) | Staff # 4 did not completed 24 hours of human service training during the training year of 09/01/2014-08/31/2015. | Program specialists and direct service workers who are employed for more than 40 hours per month shall have at least 24 hours of training relevant to human services annually. | a. Administrator and CEO
Staff#4 has completed 24 hours of human service training as required by regulation training relevant to human services annually and his training records have been updated in employment file.
b. Moving forward, Halia¿s Administrator will conduct quarterly reviews of all training logs.
c. Maintain consistency with licensing regulations, schedule staff for all trainings that are due
d. Update the training log with year-to-date completion annual fire safety training.
[Halia will provide BHSL with the documentation of completed 24 hours of training for Staff #4, on or before 9.30.2016 DD 8.5.2016] |
04/30/2016
| Implemented |
| 6400.46(f) | Staff # 1's did not complete annual fire safety training during the training year of 09/01/2014-08/31/2015. The previous fire safety training was dated 07/14/2014.
Staff # 4's did not complete annual fire safety training during the training year of 09/01/2014-08/31/2015. The previous fire safety training was dated 03/29/2014.
| Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | e. Administrator, Residential Manager, Program Specialist and CEO
f. Staff#1 completed fire safety training on 02/06/2016 and is current.
g. Moving forward, Halia¿s Administrator will conduct quarterly reviews of all training logs.
h. Maintain consistency with licensing regulations, schedule staff for all trainings that are due
i. Update the training log with year-to-date completion annual fire safety training.
[Halia will provide BHSL with the current completed fire safety training for Staff #1, and #4 on or before 9.30.2016 DD 8.5.2016] |
04/30/2016
| Implemented |
| 6400.62(a) | Individual # 1 and # 2 can not handle poisonous substances safely.
Glade Spray which indicted to contact poison control was found unlocked on the kitchen floor next to the trash can.
Two containers of bleach, two bottles of Fabulous floor cleaner, Lysol disinfecting cleaner and Orange Glow floor cleaners were found unlocked on a shelf above the washer and dryer in the basement.
| Poisonous materials shall be kept locked or made inaccessible to individuals. | a. Residential manager, and Direct staff
b. Halia management has ensure that all poisonous substances are safely locked away from Individual # 1 and # 2 to ensure their health and safety.
c. To prevent reoccurrence of non-compliance in this area, HHCS management will develop weekly tracking tool (monthly/weekly site checklist) to report and ensure all furniture and equipment are in working condition and poisonous substances are kept locked away from individuals.
t. |
04/30/2016
| Implemented |
| 6400.64(a) | There was a black circular stain consistent with dirt approximately 2 feet wide on the ceiling surrounding the ceiling fan.
There was a paint can filled with a thick black substance and a few cigarette butts found under the kitchen sink.
There was a rag stained with a black substance found under the kitchen sink.
There was a strong odor originating from the cabinets under the sink.
There was a black substance consistent with mold under the bath mat in the tub.
There was rust on the drain in the bath tub.
There was a black substance consistent with mold along the outside perimeter of the bath tub.
There was a cardboard box filled with used and unused Adult incontinence products and used latex gloves in Individual # 1's closet. | Clean and sanitary conditions shall be maintained in the home. | CEO, Financial Office, Residential manager, and Administrator
Halia has repaired and/or replacing all broken items: (i.e.: broken doors, missing handles, table legs, microwave stand, hand rails, holes in dining room wall, window pane trim, window screen, doors hangers, door knobs, hot water handles, bedroom doors, shower walls, vanity, floor, etc.) to ensure they are in good repair and working conditions.
Administrator and residential manager are responsible to report if any furniture, fixtures, equipment are clean, sturdy, in good repair, in working condition, and non-hazardous.
To prevent reoccurrence of non-compliance in this area, HHCS management will do a weekly walk-through ensuring that all individuals bedroom is fully furnished. (attachment#10) |
04/30/2016
| Implemented |
| 6400.67(a) | There were three holes in dining room wall approximately an inch to two inches in length.
The window pane trim was broken on the door leading to the backyard.
There was approximately a one foot tear in the window screen located in the back room.
Individual # 1's bedroom door top hinge was broken resulting in the door being unable to close.
There was a hole the size of the door knob on the wall in Individual # 2's bedroom.
The door knob on the bathroom door was broken.
There was approximately a six inch hole on the bathroom door.
The hot water handle was not secured to the shower wall.
The wood on the top right side of the bathroom door was peeling away.
There was a cabinet door missing from the bathroom¿s vanity.
| Floors, walls, ceilings and other surfaces shall be in good repair. | CEO, Financial Office, Residential manager, and Administrator
Halia has repaired and/or replacing all broken items: (i.e.: broken doors, missing handles, table legs, microwave stand, hand rails, holes in dining room wall, window pane trim, window screen, doors hangers, door knobs, hot water handles, bedroom doors, shower walls, vanity, floor, etc.) to ensure they are in good repair and working conditions.
Administrator and residential manager are responsible to report if any furniture, fixtures, equipment are clean, sturdy, in good repair, in working condition, and non-hazardous.
To prevent reoccurrence of non-compliance in this area, HHCS management will do a weekly walk-through ensuring that all individuals bedroom is fully furnished. (attachment#10) |
04/30/2016
| Implemented |
| 6400.71 | The emergency telephone numbers listed did not include 911, poison control, the police department or the fire department. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| a. Residential manager, and Direct staff
b. Halia management has ensure that all home has an emergency telephone numbers including 911
c. To prevent reoccurrence of non-compliance in this area, HHCS management use weekly tracking tool to ensure that all requirement/regulations are adhere to. |
04/30/2016
| Implemented |
| 6400.73(a) | The handrail for the staircase leading upstairs did not extend the length of the staircase leaving approximately four stairs without a handrail. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | CEO, Financial Office, Residential manager, and Administrator
Halia has repaired and/or replacing all broken items: (i.e.: broken doors, missing handles, table legs, microwave stand, hand rails, holes in dining room wall, window pane trim, window screen, doors hangers, door knobs, hot water handles, bedroom doors, shower walls, vanity, floor, etc.) to ensure they are in good repair and working conditions.
Administrator and residential manager are responsible to report if any furniture, fixtures, equipment are clean, sturdy, in good repair, in working condition, and non-hazardous.
To prevent reoccurrence of non-compliance in this area, HHCS management will do a weekly walk-through ensuring that all individuals bedroom is fully furnished. (attachment#10) |
04/30/2016
| Implemented |
| 6400.76(a) | The door on the microwave stand in the kitchen was broken.
Individual # 1's dresser located in the bedroom was missing handles.
There were three wrought iron chairs with broken legs discarded in the back yard.
There was a kitchen table with a broken leg located in the back room.
| Furniture and equipment shall be nonhazardous, clean and sturdy. | CEO, Financial Office, Residential manager, and Administrator
Halia has repaired and/or replacing all broken items: (i.e.: broken doors, missing handles, table legs, microwave stand, hand rails, holes in dining room wall, window pane trim, window screen, doors hangers, door knobs, hot water handles, bedroom doors, shower walls, vanity, floor, etc.) to ensure they are in good repair and working conditions.
Administrator and residential manager are responsible to report if any furniture, fixtures, equipment are clean, sturdy, in good repair, in working condition, and non-hazardous.
To prevent reoccurrence of non-compliance in this area, HHCS management will do a weekly walk-through ensuring that all individuals bedroom is fully furnished. (attachment#10) |
04/30/2016
| Implemented |
| 6400.76(d) | There was only one couch in the living room. | In homes serving eight or fewer individuals, there shall be a sufficient amount of living and family room furniture to seat all individuals at the same time. | CEO, Financial Office, Residential manager, and Administrator
Halia has repaired and/or replacing all broken items: (i.e.: broken doors, missing handles, table legs, microwave stand, hand rails, holes in dining room wall, window pane trim, window screen, doors hangers, door knobs, hot water handles, bedroom doors, shower walls, vanity, floor, etc.) to ensure they are in good repair and working conditions.
Administrator and residential manager are responsible to report if any furniture, fixtures, equipment are clean, sturdy, in good repair, in working condition, and non-hazardous.
To prevent reoccurrence of non-compliance in this area, HHCS management will do a weekly walk-through ensuring that all individuals bedroom is fully furnished. (attachment#10) |
04/30/2016
| Implemented |
| 6400.81(k)(3) | Individual # 1's bed did not have a pillow.
Individual # 3's bed did not have a pillow, linens or a blanket.
| In bedrooms, each individual shall have the following: Bedding, including pillow, linens and blankets appropriate for the season. | a. Residential Manager, Administrator, Direct Staff Person
b. All missing items: mirrors, chest of drawers, dressers, pillows, linens, and or blankets, appropriate for the season are being purchased and installed in each concerned individual¿s bedroom.
c. Monthly/weekly physical site checklist tool will be utilized to ensure that all conditions of site is maintained in the home. Hazardous substances removed, all furnishing, equipment are in proper working condition.
d. To prevent reoccurrence of non-compliance in this area, HHCS management will develop weekly tracking tool (monthly/weekly site checklist) to report and ensure all furniture and equipment are in working condition. Management will continue to provide trainings annually, and weekly review of the tool and follow-up with replacement and repairs.
(Attachment#10) |
04/30/2016
| Implemented |
| 6400.81(k)(4) | Individual # 3 did not have a chest of drawers in their bedroom. | In bedrooms, each individual shall have the following: A chest of drawers. | h. Administrator, Residential Manager, Program Specialist and CEO
i. Staff#3 completed DMA annual practicum on 10/28/2015, but recertification record was unavailable at time of inspection.
j. Halia has obtained the recertification record, and is placed on the staff employment file.
k. Halia has developed a tracking tool to ensure all staff are current/up-to-date with the Department's Medication Administration annual practicum.
l. Moving forward, Halia¿s Administrator will conduct quarterly reviews of all training logs.
m. Maintain consistency with licensing regulations, schedule staff for all trainings that are due.
n. Update the training log with date of completion for all completed. |
04/30/2016
| Implemented |
| 6400.81(k)(6) | Individual # 1, # 2 and # 3 did not have mirrors in their bedrooms. | In bedrooms, each individual shall have the following: A mirror. | a. CEO, Financial Office, Residential manager, and Administrator
b. Halia has purchased new comforters and two pillows for Individual #1.
c. Administrator and residential manager are responsible to report if any pillow is missing and request for replacement of beddings, pillows, bed sheets, bedroom furnishers.
h. To prevent reoccurrence of non-compliance in this area, HHCS management will do a weekly walk-through ensuring that all individuals bedroom is fully furnished. |
04/11/2016
| Implemented |
| 6400.106 | There was no documentation that the furnaces were cleaned. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| a. CEO, and Administrator
b. A professional furnace cleaning company has been secured to serve all furnaces in all homes.
c. To prevent reoccurrence of non-compliance, HHCS will conduct periodic self-checks, and 6 months checks of all furnaces to ensure that they are clean and serviceable with written documentation of the inspection and cleaning records kept on file.[Documentation of all furnaces being cleaned will be sent to BHSL by 9.30.2016 DD 8.5.16] |
04/30/2016
| Implemented |
| 6400.112(a) | There were no fire drill records. | An unannounced fire drill shall be held at least once a month. | a. Residential Manager, Administrator, Direct Staff Person
b. Unannounced fire drills will be coordinated and conducted monthly in each home.
c. The residential manager will provide oversight to ensure follow through.
d. All staff have received annual fire safety training,
e. All homes have had fire drills using alternative route other than front door on 04/07/2016.
f. All fire drills records are now kept in the home associated with the drill, and is to be available for review by state license inspector when required.
g. To prevent reoccurrence of non-compliance in this area, HHCS management will develop monthly tracking tool to report and ensure that monthly fire drills are completed. Management will continue to provide trainings annually.[Monthly Fire drills beginning with the month following the onsite inspection, 3.2016 to the current month 9.2016 will be sent to BHSL by 9.30.2016 DD 9.7.16] |
04/30/2016
| Implemented |
| 6400.144 | The February 2016 MAR for individual #3 indicated blood glucose readings were completed 7:30am, 11:30am and 4:30pm from 02/01/2016-2/26/2016. The glucometer readings from 02/01/2016-02/26/2016 were inconsistent with the readings recorded on the MAR. | 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.
| a. CEO, and Administrator, and Nurse
b. Halia immediately contracted a registrar nurse who administrated and recorded glucometer readings The also trained all staff assigned specifically to this home on how to properly read and record blood glucose levels.
c. On 2/27/2016 thru 3/1/2016, Staff #1, #2, #3, #5, #7 and #8 received and completed training in diabetes patient education, which include the correct way to read and record the levels indicated on the glucometer.
d. The agency nurse will be responsible to check daily recordings to ensure that the right reading is indicated on the MAR.
e. In the future, Halia management will conduct trainings annually, and conduct on-going on-site monitoring to prevent reoccurrence. Halia further promised to change methods and practices by following the medication administration procedure, and will implement proactive approach to avoid recurrences. A further training in diabetes education has been arranged with a certified diabetes educator scheduled for 4/15/2016 [Documentation of Medication Administration training for Staff #1,#2,#3,#5,#7, and #8 will be forwarded to the department along with documentation of the Diabetes Management Training For all staff working with individual #3 by 9.30.2016 DD 9.7.16] |
04/11/2016
| Implemented |
| 6400.161(b) | Triamcinolone .1% cream was found unlocked in the upstairs hallway closet. | Prescription and potentially toxic nonprescription medications shall be kept in an area or container that is locked, unless it is documented in each individual's assessment that each individual in the home can safely use or avoid toxic materials. | a. Residential manager, Administrator, Agency nurse
b. Halia has addressed the issue of safely disposing of discontinued medications.
c. Halia has established a policy that addresses medication disposal process. All staff will receive ongoing training on how to ensure safe methods of disposal or destroying of medication. Halia¿s policy states that all discontinued and expired medications will be returned to the pharmacy. (see attachment#5)
d. To avoid a recurrence of this violation, Residential Manager and Agency Nurse will conduct daily check and reported on a form indicating the name, doses, quantity of medication to be returned to the pharmacy. |
04/30/2016
| Implemented |
| 6400.161(d) | Lantus -100 (insulin) needs to be refrigerated and was found stored in a bag in a kitchen cabinet. | Prescription and nonprescription medications shall be stored under proper conditions of sanitation, temperature, moisture and light. | [Provider will ensure that all medication is stored under proper conditions effective upon receipt of this plan of correction. Additionally, program designee will complete monthly audits of all individuals medication boxes to ensure all medications are current, stored properly, and locked beginning upon receipt of this plan of correction. Beginning October 2016 program designee or nurse will complete a quarterly audit of twenty percent of those monthly audits conducted. DD 9.7.2016] |
09/07/2016
| Implemented |
| 6400.161(e) | Atrovent 0.02% solution expired on 02/07/2015 and was in the home. | Discontinued prescription medications shall be disposed of in a safe manner. | a. Residential manager, Administrator, Agency nurse
b. Halia has addressed the issue of safely disposing of discontinued medications.
c. Halia has established a policy that addresses medication disposal process. All staff will receive ongoing training on how to ensure safe methods of disposal or destroying of medication. Halia¿s policy states that all discontinued and expired medications will be returned to the pharmacy. (see attachment#5)
d. To avoid a recurrence of this violation, Residential Manager and Agency Nurse will conduct daily check and reported on a form indicating the name, doses, quantity of medication to be returned to the pharmacy. |
04/30/2016
| Implemented |
| 6400.164(a) | Individual # 2 is prescribed Hydrocodn -325 and it was not listed on the MAR. | 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. | a. Administrator, residential manager
b. Individual #2 is no longer prescribed hydrocodone-325 (see attachment # 4)
c. All medications have been rescheduled for drop-off at Halia¿s mean office for initial review
d. Medications and MAR received from the pharmacy will be reviewed by the Administrator prior to certify that all medications matched the prescription slip and are accounted for on MAR before sending them off to the homes.
e. The Administrator will provide ongoing monitoring, and training of staff to report any and all discrepancies.
f. Moving forward, Halia¿s Administrator will conduct monthly reviews of all MARs to avoid a repeat of medication not listed on MAR. If any discrepancy is found on the MAR and/or prescription slip, the Administrator/staff will communicate with the doctor/pharmacy to correct the discrepancy. |
04/11/2016
| Implemented |
| 6400.168(a) | Staff # 6 administered medications in November 2015, December 2015, January 2016 and February 2016 and did not complete the Department¿s Medication Administration course.
Staff # 9 administered medications in January 2016 and February 2016 and did not complete the Department¿s Medication Administration course.
| In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. | a. Administrator, Residential Manager, Program Specialist and CEO
b. Staff#6 completed DMA initial training on 07/11/2015, but recertification record was unavailable at time of inspection.
c. Halia has obtained the recertification record, and is placed on the staff employment file.
d. Halia has developed a tracking tool to ensure all staff are current/up-to-date with the Department's Medication Administration annual practicum.
e. Moving forward, Halia¿s Administrator will conduct quarterly reviews of all training logs.
f. Maintain consistency with licensing regulations, schedule staff for all trainings that are due.
g. Update the training log with date of completion for all completed.
[Documentation of Medication Administration training for Staff #1,#2,#3,#5,#7, and #8 will be forwarded to the department along with documentation of the Diabetes Management Training For all staff working with individual #3 by 9.30.2016 DD 9.7.16] |
04/30/2016
| Implemented |
| 6400.168(b) | Staff #1, #2, #3, #5, #8 and #10 administered insulin to individual # 3 in January 2016 and February 2016 and did not complete a diabetes patient education program. | In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course and who has completed and passed a diabetes patient education program within the past 12 months that meets the National Standards for Diabetes Patient Education Programs of the National Diabetes Advisory Board, 7550 Wisconsin Avenue, Bethesda, Maryland 20205, is permitted to administer insulin injections to an individual who is under the care of a licensed physician who is monitoring the diabetes, if insulin is premeasured by licensed or certified medical personnel. | a. Nurse, residential manager, and Administrator
b. Halia has taken steps by contracting services of a registrar nurse, and an LPN part-time worker who are responsible for training, follow-ups, and monitoring staff in their responsibility of administrating insulin. The LPN worker will do weekly checks, while the Administrator provides general oversight.
c. On 2/27/2016 thru 3/1/2016, Staff #1, #2, #3, #5, #7 and #8 received and completed training in diabetes patient education conducted by the Registrar Nurse. (Attachment #2)
d. Halia plans to complete training of staff #10 in administering insulin by the target of 4/15/16. (further training with a certified Diabetes Educator (NCBDE) is schedule for Friday, 4/15/2016) (Attachment#3)
e. In the future, Halia management will continue to conduct trainings annually, and conduct on-going on-site monitoring to prevent reoccurrence. Halia further promised to change methods and practices that violate proper medications administration, and will implement proactive approach to avoid future recurrences.
[Documentation of Medication Administration training for Staff #1,#2,#3,#5,#7, and #8 will be forwarded to the department along with documentation of the Diabetes Management Training For all staff working with individual #3 but specifically for Staff #1,#2,#3,#5,#8,#10 by 9.30.2016 DD 9.7.16] |
04/30/2016
| Implemented |
| 6400.168(d) | Staff # 1 administered medication in November 2015, December 2015, January 2016 and February 2016 and did not complete the Department's Medication Administration annual practicum. Staff # 1 previously completed the Department's medication administration training course on 11/07/2014.
Staff # 3 administered medications in November 2015, December 2015, January 2016 and February 2016 and did not complete the Department's Medication Administration annual practicum. Staff # 3 previously completed the Department's medication administration training course on 10/28/2014.
Staff # 5 administered medications in November 2015 and January 2016 and did not complete the Department's Medication Administration annual practicum. Staff # 7 previously completed the Department's medication administration training course on 02/24/2014
Staff # 7 administered medications in November 2015 and December 2015, and did not complete the Department's Medication Administration annual practicum. Staff # 7 previously completed the Department's medication administration training course on 02/24/2014.
Staff # 8 administered medications in November 2015, December 2015, January 2016 and February 2016 and did not complete the Department's Medication Administration annual practicum. Staff # 8 previously completed the Department's medication administration training course on 10/08/2014.
| A staff person who administers prescription medications and insulin injections to an individual shall complete and pass the Medications Administration Course Practicum annually. | a. Administrator, Residential Manager, Program Specialist and CEO
b. Staff#1 completed DMA annual practicum on 11/07/2015, but recertification record was unavailable at time of inspection.
c. Halia has obtained the recertification record, and is placed on the staff employment file.
d. Halia has developed a tracking tool to ensure all staff are current/up-to-date with the Department's Medication Administration annual practicum.
e. Moving forward, Halia¿s Administrator will conduct quarterly reviews of all training logs.
f. Maintain consistency with licensing regulations, schedule staff for all trainings that are due.
g. Update the training log with date of completion for all completed.
[Documentation of Medication Administration training for Staff #1,#2,#3,#5,#7, and #8 will be forwarded to the department along with documentation of the Diabetes Management Training For all staff working with individual #3 by 9.30.2016 DD 9.7.16] |
04/30/2016
| Implemented |
| 6400.216(a) | Individual #1, #2, and # 3's medication administration record was found unlocked in the kitchen cabinet located to the left of the refrigerator. | An individual's records shall be kept locked when unattended. | a. Administrator, agency nurse, and residential manager
b. Halia Home Care recognizes the importance of securing the individual¿s records, and is committed to preserve the privacy, confidentiality, and security of all records including the MAR associated with the individuals we service.
c. The residential manager will ensure that this correction is maintained. has taken the following measures to properly secure Individual #1, #2, and #3¿s and all other individuals¿ medication administration records: are kept in a locked cabinet: All staff assigned in the home will receive on-site training on how to securely keep the individual MAR, and the residential manager is responsible to monitor and ensure that staff follow through with these measures. The Administrator will also conduct weekly monitoring of the home. Halia Home Care has obtained and dedicated a cabinet with lock and keys located in a secure area for the purpose of keeping all medication administration records when unattended. |
04/30/2016
| Implemented |
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