| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.43(b)(1) | Per the policy (Bulletin-00-02-09) on administering psychiatric medications as a PRN, each and every time a psychiatric medication is administered as a PRN, the CEO's authorization of the use is to be documented on the Medication Administration Record. Individual #1 was administered a psychiatric medication as a PRN on 11 occasions. There is no authorization from the CEO documented on the MAR's. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | Certified investigation incident #9048577 confirmed.
*The medication administration agency policy has been updated to include the authorization of PRN psychotropic medication documentation on the MAR.
*The CEO has been retrained on the updates to the policy
* Additional designees are trained and assigned |
07/21/2022
| Implemented |
| 6400.141(c)(3) | Individual #1 last had TDAP on 1/12/12; which is outside of the recommendations of the CDC. TDAP is to be updated every ten years. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Individual received TDap as soon as possible after discovery of missed vaccine. In addition, the house manager and residential coordinator has been retrained on regulation |
07/21/2022
| Implemented |
| 6400.141(c)(7) | Individual #1 had a gynecological exam on 6/17/21 and not again since, outside of the annual timeframe. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | The Program Specialist, house managers, the residential coordinators have been retrained on regulatory compliance in medical appointments. This includes the requirement to have a medical reason, not related to intellectual disabilities, for not having this exam annually. Training also included seeking a potential second opinion if the gynecologist cannot provide appropriate medical reasoning. |
07/21/2022
| Implemented |
| 6400.181(e)(2) | Individual #1's most recent annual assessment completed on 3/15/22 did not identify Individual #1's dislikes. | The assessment must include the following information: The likes, dislikes and interest of the individual. | The program specialist has been retrained on the assessment to include specifics of dislikes in the assessment and the contents required on the assessment in its entirety. |
07/18/2022
| Implemented |
| 6400.211(b)(2) | Individual #1's demographic information did not include their physician's name, address, or phone number. | Emergency information for each individual shall include the following: The name, address and telephone number of the individual's physician or source of health care. | Physician's name, address and phone number information has been updated and a new face sheet form has been created. The program specialist has been trained on creating this form for all new admissions, all current residents, and keeping this information up to date. |
07/20/2022
| Implemented |
| 6400.211(b)(3) | Individual #1's demographic information did not include the address and phone number of who to call for medical consent. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.
| Individuals designated person to give medical consent has been updated on her face sheet to include name, address and phone number information on an updated form created by the agency. The program specialist has been trained on creating this form for all new admissions, all current residents, and keeping this information up to date. |
07/20/2022
| Implemented |
| 6400.32(c) | Individual #1 was administered Hydroxyzine and Haloperidol as a PRN for "agitation" from January 2022 through the present. Per Bulletin-00-02-09, in order for a psychiatric medication to be administered as a PRN, there must be medical documentation clearly identifying the symptoms that must occur in order for the medications to be administered. There is no such medical documentation in Individual #1's record. In addition, Staff #2 incorrectly reported to the physician that the psychiatric medications had not been administered to Individual #1 since being prescribed. According to the SEEN Plan, Haloperidol was to be administered if Individual #1 exhibited two acts of physical aggression within an hour. On 1/16/22, Individual #1 was administered 5mg of Haloperidol as a PRN at 9:25am. According to the behavior tracking log, the only behavior Individual #1 exhibited at that time was threatening to urinate in the water while Individual #1 was bathing. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | Certified investigation incident #9048567 confirmed. Target was retrained on communicating with a doctor, Getting the most from a doctors appointment, and potential health consequences of psychiatric medication through Milestone HCQU West Training Center |
07/15/2022
| Implemented |
| 6400.165(b) | Individual #1 had Trazadone discontinued in November 2021. There was no discontinue order for this medication in the record. | A prescription order shall be kept current. | The agency's house managers, residential coordinators and Program Specialist have been trained on new practice in regards to medical documentation and follow up with the pharmacy immediately following all appointments. The managers are responsible for checking forms for accuracy and follow up with the pharmacy while obtaining clear discontinuation instructions during any appointments. They are also responsible for ensuring that all telehealth appointments are clearly documented and attempts to have the physician completed the agency form is clearly documented in the staff's impressions area of all medical forms. Residential Coordinators are responsible for oversight of these checks and the documentation, providing assistance to house managers when needed to ensure their responsibilities are completed. Program Specialist are responsible for ensuring regulatory compliance in conjunction with the program director . |
07/21/2022
| Implemented |
| 6400.181(f) | Individual #1's assessment was sent to the Supports Coordinator and Team on 3/16/22. The ISP team meeting was held on 4/12/22. The assessment was not sent 30 days prior to the Team Meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The Program Specialists have been trained on assessment dates and compliance in this area. In addition, review and training on addendums to the assessment has been completed to ensure that updates to the assessment that may need made prior to the meeting are submitted. |
07/15/2022
| Implemented |
| 6400.207(4)(I) | Individual #1 was administered Hydroxyzine and Haloperidol as a PRN for "agitation" 11 times from January 2022 until the annual inspection. In order for a psychiatric medication to be administered as a PRN, there must be medical documentation clearly identifying the symptoms that must occur in order for the medications to be administered (Bulletin-00-02-09). There is no such medical documentation in Individual #1's record. Per the policy on administering psychiatric medications as a PRN, each and every time a psychiatric medication is administered as a PRN, the CEO's authorization of the use is to be documented on the Medication Administration Record. Individual #1 was administered a psychiatric medication as a PRN on 11 occasions. There is no authorization from the CEO documented on the MAR's. According to the SEEN Plan, Haloperidol was to be administered if Individual #1 exhibited two acts of physical aggression within an hour. On 1/16/22, Individual #1 was administered 5mg of Haloperidol as a PRN at 9:25am. According to the behavior tracking log, the only behavior Individual #1 exhibited at that time was threatening to urinate in the water while Individual #1 was bathing. | A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition. | Certified investigation incident #9048513 confirmed.
*Behavior support team updated Individuals BSP with correct and up to date psychotropic medication lists and target has been retrained on the updated plan and accurate data collections.
*All staff have been retrained on updated medication administration policy and psychotropic PRN's
*Medication administration policy has been updated and outlines the use of PRN medications, appropriate forms to use, and who is responsible. |
07/21/2022
| Implemented |