Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.82(f) | There was no mirror in the basement bathroom. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Royal Home Care maintenance contractor immediately bought and installed a mirror in the bathroom (see the attached) on 7/22/2022. |
07/22/2022
| Implemented |
6400.111(c) | There was no fire extinguisher in the kitchen. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | Fire extinguishers were immediately placed at designated places (see the attached). |
07/22/2022
| Implemented |
6400.163(b) | Individual 1's 8PM medications for 7/21/22 had been removed from their blister packs ahead of their administration and were found stored in a sandwich bag. The two that remained in their blister packs were Quetiapine and Sodium Bicarbonate. | A prescription medication may not be removed from its original labeled container in advance of the scheduled administration, except for the purpose of packaging the medication for the individual to take with the individual to a community activity for administration the same day the medication is removed from its original container. | The staff responsible for removing the medications from the blister pack and placed them in a sandwich bag was immediately removed from the schedule and replaced by an experience staff pending medication administration training. The staff in question was retrained along with existing and newly hire staff of 8/18/22 on medication administration foundation, procedure, and documentation by the agency¿s med trainer (see the attached). |
08/18/2022
| Implemented |
6400.163(d) | Individual #1's PRN clonazepam, a controlled substance, was not kept behind two locks; it was in a locked closet, but the box it was stored it was not locked. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | An additional lock was immediately purchased by the administrator to keep the control substance locked in the storage (see the attached). |
07/22/2022
| Implemented |
6400.166(a)(13) | None of Individual #1's 8AM medications had been signed for in their MAR on 7/21/22. Pills missing from their blister packs indicate they have been administered. | 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. | The staff responsible for the documentation error and removing medications from the blister pack was immediately removed from the schedule and replaced by an experience staff pending medication administration training. The staff in question was retrained along with existing and newly hire staff on 8/18/22 on medication administration foundation, procedure, and documentation by the agency¿s med trainer (see the attached). |
08/18/2022
| Implemented |