| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.166(a)(4) | Individual #1 is prescribed Docusate Sodium Capsule 100mg, take 1 capsule orally as needed for constipation. On 8/23/2023, Individual #1's medication administration record did not include the name of the medication and the medication was administered 8/19/2023 and 8/20/2023. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | ¿ A plan to fix the immediate problem
o WHO: QLS management and staff
o WHAT: QLS management will retrained the staff that did not sign off on the MAR, as well as added a reminder added to the daily log in CareSoft to check that the medication administration was properly completed for this individual for all medication times during shift including PRNs.
o WHEN and HOW: QLS management has set up staff that failed to complete their medication administration documentation for training on College of Direct Support to be completed by 10/1/2023. Beginning 10/1/2023 a task will be added to the eMAR system to generate at 8a, 4p, 8p ensuring that staff have properly administered and documented any PRN medications. |
10/01/2023
| Implemented |
| 6400.166(a)(5) | Individual #1 is prescribed Docusate Sodium Capsule 100mg, take 1 capsule orally as needed for constipation.On 8/23/2023, Individual #1's medication administration record did not include the strength of the medication and the medication was administered 8/19/2023 and 8/20/2023. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | ¿ A plan to fix the immediate problem
o WHO: QLS management and staff
o WHAT: QLS management will retrained the staff that did not sign off on the MAR, as well as added a reminder added to the daily log in CareSoft to check that the medication administration was properly completed for this individual for all medication times during shift including PRNs.
o WHEN and HOW: QLS management has set up staff that failed to complete their medication administration documentation for training on College of Direct Support to be completed by 10/1/2023. Beginning 10/1/2023 a task will be added to the eMAR system to generate at 8a, 4p, 8p ensuring that staff have properly administered and documented any PRN medications. |
10/01/2023
| Implemented |
| 6400.166(a)(6) | Individual #1 is prescribed Docusate Sodium Capsule 100mg, take 1 capsule orally as needed for constipation. On 8/23/2023, Individual #1's medication administration record did not include the dosage form for the medication and the medication was administered 8/19/2023 and 8/20/2023. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | ¿ A plan to fix the immediate problem
o WHO: QLS management and staff
o WHAT: QLS management will retrained the staff that did not sign off on the MAR, as well as added a reminder added to the daily log in CareSoft to check that the medication administration was properly completed for this individual for all medication times during shift including PRNs.
o WHEN and HOW: QLS management has set up staff that failed to complete their medication administration documentation for training on College of Direct Support to be completed by 10/1/2023. Beginning 10/1/2023 a task will be added to the eMAR system to generate at 8a, 4p, 8p ensuring that staff have properly administered and documented any PRN medications. |
10/01/2023
| Implemented |
| 6400.166(a)(7) | Individual #1 is prescribed Docusate Sodium Capsule 100mg, take 1 capsule orally as needed for constipation. On 8/23/2023, Individual #1's medication administration record did not include the dose of the medication and the medication was administered 8/19/2023 and 8/20/2023. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | ¿ A plan to fix the immediate problem
o WHO: QLS management and staff
o WHAT: QLS management will retrained the staff that did not sign off on the MAR, as well as added a reminder added to the daily log in CareSoft to check that the medication administration was properly completed for this individual for all medication times during shift including PRNs.
o WHEN and HOW: QLS management has set up staff that failed to complete their medication administration documentation for training on College of Direct Support to be completed by 10/1/2023. Beginning 10/1/2023 a task will be added to the eMAR system to generate at 8a, 4p, 8p ensuring that staff have properly administered and documented any PRN medications. |
10/01/2023
| Implemented |
| 6400.166(a)(8) | Individual #1 is prescribed Docusate Sodium Capsule 100mg, take 1 capsule orally as needed for constipation. On 8/23/2023, Individual #1's medication administration record did not include the route of administration for the medication and the medication was administered 8/19/2023 and 8/20/2023. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | ¿ A plan to fix the immediate problem
o WHO: QLS management and staff
o WHAT: QLS management will retrained the staff that did not sign off on the MAR, as well as added a reminder added to the daily log in CareSoft to check that the medication administration was properly completed for this individual for all medication times during shift including PRNs.
o WHEN and HOW: QLS management has set up staff that failed to complete their medication administration documentation for training on College of Direct Support to be completed by 10/1/2023. Beginning 10/1/2023 a task will be added to the eMAR system to generate at 8a, 4p, 8p ensuring that staff have properly administered and documented any PRN medications. |
10/01/2023
| Implemented |
| 6400.166(a)(9) | Individual #1 is prescribed Docusate Sodium Capsule 100mg, take 1 capsule orally as needed for constipation. On 8/23/2023, Individual #1's medication administration record did not include the frequency of administration for the medication and the medication was administered 8/19/2023 and 8/20/2023. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | ¿ A plan to fix the immediate problem
o WHO: QLS management and staff
o WHAT: QLS management will retrained the staff that did not sign off on the MAR, as well as added a reminder added to the daily log in CareSoft to check that the medication administration was properly completed for this individual for all medication times during shift including PRNs.
o WHEN and HOW: QLS management has set up staff that failed to complete their medication administration documentation for training on College of Direct Support to be completed by 10/1/2023. Beginning 10/1/2023 a task will be added to the eMAR system to generate at 8a, 4p, 8p ensuring that staff have properly administered and documented any PRN medications. |
10/01/2023
| Implemented |
| 6400.166(a)(11) | Individual #1 is prescribed Docusate Sodium Capsule 100mg, take 1 capsule orally as needed for constipation. On 8/23/2023, Individual #1's medication administration record did not include the diagnosis or purpose for the medication and the medication was administered 8/19/2023 and 8/20/2023. | 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. | ¿ A plan to fix the immediate problem
o WHO: QLS management and staff
o WHAT: QLS management will retrained the staff that did not sign off on the MAR, as well as added a reminder added to the daily log in CareSoft to check that the medication administration was properly completed for this individual for all medication times during shift including PRNs.
o WHEN and HOW: QLS management has set up staff that failed to complete their medication administration documentation for training on College of Direct Support to be completed by 10/1/2023. Beginning 10/1/2023 a task will be added to the eMAR system to generate at 8a, 4p, 8p ensuring that staff have properly administered and documented any PRN medications. |
10/01/2023
| Implemented |
| 6400.166(a)(12) | Individual #1 is prescribed Docusate Sodium Capsule 100mg, take 1 capsule orally as needed for constipation. On 8/23/2023, Individual #1's medication administration record did not include the date and time of administration for the medication and the medication was administered 8/19/2023 and 8/20/2023. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration. | ¿ A plan to fix the immediate problem
o WHO: QLS management and staff
o WHAT: QLS management will retrained the staff that did not sign off on the MAR, as well as added a reminder added to the daily log in CareSoft to check that the medication administration was properly completed for this individual for all medication times during shift including PRNs.
o WHEN and HOW: QLS management has set up staff that failed to complete their medication administration documentation for training on College of Direct Support to be completed by 10/1/2023. Beginning 10/1/2023 a task will be added to the eMAR system to generate at 8a, 4p, 8p ensuring that staff have properly administered and documented any PRN medications. |
10/01/2023
| Implemented |
| 6400.166(a)(13) | Individual #1 is prescribed Docusate Sodium Capsule 100mg, take 1 capsule orally as needed for constipation. On 8/23/2023, Individual #1's medication administration record did not include the name and initials of the person who administered the medication 8/19/2023 and 8/20/2023. | 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. | ¿ A plan to fix the immediate problem
o WHO: QLS management and staff
o WHAT: QLS management will retrained the staff that did not sign off on the MAR, as well as added a reminder added to the daily log in CareSoft to check that the medication administration was properly completed for this individual for all medication times during shift including PRNs.
o WHEN and HOW: QLS management has set up staff that failed to complete their medication administration documentation for training on College of Direct Support to be completed by 10/1/2023. Beginning 10/1/2023 a task will be added to the eMAR system to generate at 8a, 4p, 8p ensuring that staff have properly administered and documented any PRN medications. |
10/01/2023
| Implemented |