| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | At 11:59AM, a plastic spray bottle with an unknown substance and masking tape with the word, "straight" and other illegible words hand-written on it, was in the cabinet under the sink in the kitchen of the home. | Poisonous materials shall be stored in their original, labeled containers. | The inspection discovered an unlabeled bottle under the sink along with other bottles that contain cleaning supplies household chemicals. Apparently, the bottle have been used to mix solutions for cleaning in an effort to limit the amount of chemicals used in the cleaning process. The bottle had not been rinsed and empty. The bottle was immediately disposed of. Staff are trained on the agency policy regarding the storage and use of cleaning supplies and household chemicals and that all household chemicals must be kept In the original labeled container. Any containers used to mix solutions on-site must be rinsed and emptied after the end of each year¿s and the container store properly. This training took place on March 25, 2024. Any future staff will be trained on this same policy. |
03/25/2024
| Implemented |
| 6400.163(d) | At 12:04PM, bottles with small amounts of Individual #1's prescribed liquid medications, Carbamazepine and Levocarnitine, were in a plastic shopping bag, hanging from a knob on a cabinet in the kitchen of the home. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | The inspection found bottles of individual #1¿s liquid medication in a plastic shopping bag hanging from off on a cabinet in the kitchen of the home. The place where the bottles were hanging is where individual #1¿s medication is prepare for administration. Apparently, the staff had prepared the medication for administration and in the process had emptied one of the Stock bottles and had not yet removed the label and disposed of the empty bottle. The stock bottlers were not locked even though they contained a very small amount of the medication. The staff on March 25, 2024, were retrained on the agency Policy and procedure regarding the removal of labels disposal of empty medication bottles. New staff will be retrained as part of the orientation process. |
03/25/2024
| Implemented |
| 6400.165(e) | Individual #1 is prescribed Ibuprofen with instructions to, "take 6 teaspoonfuls every 8 hours." This medication has not been administered in March 2024 and "PRN" was written on the March 2024 Medication Administration Record. There are no physician's orders listing this medication as Pro Re Nata. Individual #2 is prescribed Mometasone Furoate with instructions to, "Apply to the affected area twice daily-for topical use." This medication has not been administered in March 2024 and "PRN" was written on the March 2024 Medication Administration Record. There are no physician's orders listing this medication as Pro Re Nata. | 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. | The inspection discovered that entries on the MAR for medications that are and have been given as an did not have the words as needed listed on the MAR. The MAR¿s I received pre-printed from the pharmacy. Apparently, the prescribing physician did not include as needed in the medication administration instructions even though it was understood that the prescription, ibuprofen, would be given as needed rather than constantly. The staff and the prescribing physician had reviewed the medications multiple times, and the prescribing physician and even written a standing order for ibuprofen to be given as needed, but the change on the MAR had never been made. The prescribing physician has been contacted and the pharmacy has also been contacted to make the change on the MAR. The staff has been retrained, March 25, 2024, regarding the importance of medication being recorded on the MAR and to check when administering a PRN medication that the medication is listed on the MAR as a PRN medication. |
03/25/2024
| Implemented |
| 6400.166(a)(8) | Individual #1 is prescribed Baclofen with instructions to, "take 1 tablet by mouth 3 times daily at 6-2-10." Staff Interviews revealed that this medication is dissolved in water and administered via a G-Tube. Individual #1's prescribed medications, Phenobarbital and Carbamazepine have instructions to, "take by mouth." Staff interviews revealed that these medications are administered via Individual #1's G-Tube. Individual #1's March 2024 Medication Administration Record does not document the route of administration for Levocarnitine and Ibuprofen. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | The inspection discovered discrepancies between the prescribed instructions listed on the MAR in the actual practice of administering medications. The MAR listed medications is being administered by mouth when individual #1 is NPO and receives all his medications through G-tube. Two other medications do not even list a route of administration. The staff and the prescribing physician have reviewed the medication list multiple times but, apparently, address the discrepancy that the individual in question is NPO and the prescription states that the medication is to be given by mouth. The prescribing physician has been contacted and a request is made to update the prescription to reflect the medication to be administered via G-tube. Additionally, the pharmacy that preprints our MAR¿s has contacted and requested to update the MAR. On March 25, 2024, the staff were retrained regarding the importance of the prescribing instructions listed on the MAR and that if there is a discrepancy it should be noted and in accordance with agency policy, a request to have the discrepancy addressed be made. This will be highlighted when it is addressed in medication administration training with new staff as they are trained. |
03/25/2024
| Implemented |
| 6400.166(b) | Baclofen, Carbamazepine, Valproic Acid and Levocarnitine prescribed to Individual #1 were not initialed as administered at 6:00AM on 3/12/2024. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | During the inspection, it was discovered that medication that had been administered previously in the day had not been initial in the proper date and time spot on the MAR. Apparently, staff and administered medication on the preview shift but had failed to initial the proper spot on the MAR. This was confirmed because the administration of the medication was noted on the daily log. During the medication administration training, the importance of initialing The MAR when the medication is administered is emphasized. All staff, on May 25, 2024, were retrained on the importance of initialing the MAR at the time the medication is administered. In light of the discovery, during the inspection, the training included the importance of initialing the proper date and time spot on the MAR at the time the medication is administered will be emphasized. It is each staff persons responsibility to check the MAR as they administer medication to make sure that each medication is administered an initial for as it is given. |
03/25/2024
| Implemented |