Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.64(f) | There was trash and debris that lined the back exit walkway at the kitchen exit and needs to be cleaned. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | The trash and debris was cleared out immediately after the inspection was conducted on 4/20/2022. |
04/20/2022
| Implemented |
6400.71 | There were no emergency numbers found at or near the telephone in the living room area. | 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.
| Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center etc. was printed out and taped down near each landline telephone at the facility. |
04/23/2021
| Implemented |
6400.72(a) | There was no screen found in the window in an unoccupied bedroom | Windows, including windows in doors, shall be securely screened when windows or doors are open. | The CFO who¿s also owns a licensed construction company, had 1 of his contractors come conduct measurements and the missing screen was replaced on 4/23/22. |
04/23/2022
| Implemented |
6400.76(a) | The headboard in Individual #2's bedroom is not secure and needs to be secured to the bed frame. | Furniture and equipment shall be nonhazardous, clean and sturdy. | The CFO who¿s also owns a licensed construction company, had 1 of his contractors come out and secure the headboard to individual #2's bedframe, making it sturdy on 4/23/22. |
04/23/2022
| Implemented |
6400.142(e) | Individual #2 was ordered to have 4 teeth extracted during the dental visit on 3/5/2020. The exam form states that those 4 teeth were impacted and infected. There was another referral made during the dental visit on 3/15/2021. As of most recent dental visit on 4/16/2022, those same 4 teeth have not been extracted. | Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. | The program specialist contacted "Special Smiles" and had Individual #2 dental appointment scheduled for 6/29/22 for teeth extractions. |
04/20/2022
| Implemented |
6400.144 | Individual #2's ISP states that he is currently being prescribed "Deep Sea Premium Saline .06% Spray" for Congestion, however this medication was not listed on the MAR, nor was it present during the time of inspection. | 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.
| The program specialist and/or house manager will participate in individuals ISP meeting and was instructed to cross reference all medications listed and being updated on the ISP to coincide and match all medications/mgs that¿s documented on the providers MARS log as well as prescribed medications. |
05/01/2022
| Implemented |
6400.163(d) | There were medication boxes left in unlocked kitchen cabinets for both Individuals who reside in this 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. | During staff meeting on 5/1/22 all House managers were given new medication lock boxes with 3-digit lock codes to secure all medications at each facility. |
05/01/2022
| Implemented |
6400.165(b) | During the medication review for Individual #2, Lithium carb cap 300 mg 8am blister pack has 11 pills left. Lithium card cap 300 mg 8pm blister pack has 9 pills left. There are no notes on the MAR or on blister packs to determine if this is an accurate count. Staff was not able to explain the excess/shortage of meds at the different times of day. | A prescription order shall be kept current. | All staff were retrained on medication administration on 5/1/22. All prescription medications will be administered as prescribed. |
05/01/2022
| Implemented |
6400.165(c) | During the medication review for Individual #2, Lithium carb cap 300 mg 8am blister pack has 11 pills left. Lithium card cap 300 mg 8pm blister pack has 9 pills left. There are no notes on the MAR or on blister packs to determine if this is an accurate count. Staff was not able to explain the excess/shortage of meds at the different times of day. | A prescription medication shall be administered as prescribed. | All staff were retrained on medication administration on 5/1/22. All prescription medications will be administered as prescribed. |
05/01/2022
| Implemented |
6400.165(c) | Regarding Individual #2's medication review: the Cetirizine 10mg (to be administered at 8am) was not recorded as administered on the MAR. | A prescription medication shall be administered as prescribed. | All staff were retrained on medication administration on 5/1/22. All prescription medications will be administered as prescribed. |
05/01/2022
| Implemented |
6400.165(c) | Regarding Individual #2's medication review: the Haloperidol 10mg tab (to be administered 8am and 8pm). The 8 PM blister pack suggests 21 pills were administered, when it should be only 20 administered (as of the morning of 4/21/22). It could not be determined when this medication was administered as a result. | A prescription medication shall be administered as prescribed. | All staff were retrained on medication administration on 5/1/22. All prescription medications will be administered as prescribed. |
05/01/2022
| Implemented |
6400.165(c) | Regarding Individual #2's medication review: the Clonidine 0.1mg is the be administered 3 times a day (8am,5pm,8pm). The 8am dosage was not signed out for on MAR on 4/21/22. it could not be determined if the medication was administered as it was not recorded on the MAR. | A prescription medication shall be administered as prescribed. | All staff were retrained on medication administration on 5/1/22. All prescription medications will be administered as prescribed. |
05/01/2022
| Implemented |
6400.165(e) | Regarding Individual #2's medication review: the Guaifenesin 600mg tab is listed on the blister pack as to be administered at 8am & 8pm. However, the MAR lists this medication as a PRN-1 by mouth 2x's a day for mucus as needed. There were 2 blister packs for each time of day of this medication, none was used. | 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. | All staff were retrained on medication administration on 5/1/22. All prescription medications will be administered as prescribed. |
05/01/2022
| Implemented |
6400.165(e) | Regarding Individual #2's medication review: the Naproxen 250mg is listed on the blister packs as to be administered twice a day at 8am & 8pm. However, the MAR lists the Naproxen 250mg tab as needed for pain (PRN)
If the prescriber changed the order the mar and blister packs must be updated to reflect the change. The staff wrote (PRN) on the existing medications that list the meds to be given twice a day. | 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. | All staff were retrained on medication administration on 5/1/22. All prescription medications will be administered as prescribed. |
05/01/2022
| Implemented |
6400.165(g) | There was a 5-month lag time between Individual #2's most recent psych med reviews. The Individual was seen on 10/13/21, then not again until 3/30/22. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | The medical liaison scheduled individual #2's psych med review for 6/09/22. |
06/09/2022
| Implemented |
6400.166(b) | Regarding Individual #2's medication review: the Cetirizine 10mg (to be administered at 8am) was not recorded as administered on the MAR. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | All prescription medication will be administered as prescribed. All staff were retrained on medication administration on 5/1/22. |
05/01/2022
| Implemented |
6400.166(b) | Regarding Individual #2's medication review: the Clonidine 0.1mg is the be administered 3 times a day (8am,5pm,8pm). The 8am dosage was not signed out for on MAR on 4/21/22. it could not be determined if the medication was administered as it was not recorded on the MAR. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | All prescription medication will be administered as prescribed. All staff were retrained on medication administration on 5/1/22. |
05/01/2022
| Implemented |
6400.166(d) | Regarding Individual #2's medication review: the Clonidine 0.1mg is the be administered 3 times a day (8am,5pm,8pm). The 8am dosage was not signed out for on MAR on 4/21/22. it could not be determined if the medication was administered as it was not recorded on the MAR. | The directions of the prescriber shall be followed. | All prescription medication will be administered as prescribed. All staff were retrained on medication administration on 5/1/22. |
05/01/2022
| Implemented |
6400.166(d) | Regarding Individual #2's medication review: the Cetirizine 10mg (to be administered at 8am) was not recorded as administered on the MAR. | The directions of the prescriber shall be followed. | All prescription medication will be administered as prescribed. All staff were retrained on medication administration on 5/1/22. |
05/01/2022
| Implemented |
6400.166(d) | Regarding Individual #2's medication review: the Haloperidol 10mg tab (to be administered 8am and 8pm). The 8 PM blister pack suggests 21 pills were administered, when it should be only 20 administered (as of the morning of 4/21/22). It could not be determined when this medication was administered as a result. | The directions of the prescriber shall be followed. | All prescription medication will be administered as prescribed. All staff were retrained on medication administration on 5/1/22. |
05/01/2022
| Implemented |
6400.166(d) | Regarding Individual #2's medication review: the Naproxen 250mg is listed on the blister packs as to be administered twice a day at 8am & 8pm. However, the MAR lists the Naproxen 250mg tab as needed for pain (PRN)
If the prescriber changed the order the mar and blister packs must be updated to reflect the change. The staff wrote (PRN) on the existing medications that list the meds to be given twice a day. | The directions of the prescriber shall be followed. | All prescription medication will be administered as prescribed. All staff were retrained on medication administration on 5/1/22. |
05/01/2022
| Implemented |