Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.34(a) | The home shall inform and explain individual rights and the process to report a rights violation to the individual and persons designated by the individual upon admission to the home and annually there after. The individual rights need to be updated to reflect the current regulations. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Client service team did not match the new regulations to the current documentation being given to individuals. Client Rights policy was revised and is being reviewed with all staff and individuals during January 2021.Client Rights policy will be reviewed with all clients upon admission and annually there after. Quality Management will review updates from ODP regularly to ensure policy is updated to comply with current regulations. |
01/07/2021
| Implemented |
6400.163(h) | The prescription was dispensed on 10/29/19. This PRN is out of date. Also Ocean Nasal Spray 0.65% nose spray directed to give 2 sprays in each nostril as needed every 2 hours was dispensed on 10/29/19. This PRN is also out of date. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Pharmacy had not removed the medication from the MAR after it was discontinued and staff failed to remove the medication from the home & MAR. Medication was removed on 12/02/2020 and discontinue order was confirmed . LVAS is in process to switch pharmacies to Hartzell's Pharmacy. This decision was made due to ongoing issues with the current pharmacy. Switch should be full by 3/15/2021 |
03/15/2021
| Implemented |
6400.166(a)(6) | The medication record shall be kept including the diagnosis or purpose for the medication. Medication Clozapine 50mg listed on the MARS sheet does not have diagnosis or purpose for the medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | The pharmacy refuses to add this information and no-one has been handwriting it onto the MAR . Diagnosis and reason for medication added to January MARs by 1/14/2021. LVAS is in process to switch pharmacies to Hartzell's Pharmacy. This decision was made due to ongoing issues with the current pharmacy. Hartzell's will print this information on the forms Switch should be full by 3/15/2021
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03/15/2021
| Implemented |
6400.166(a)(7) | The medication record shall be kept including the dose of medication. Individual #1 medication for Clozapine 50mg is listed on the MARS to take one tablet twice a day daily. The blister pack directions states that 1.5 tablets is to be taken twice a day. The blister pack also reflected 1.5 tablets in the blister. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | Administrtive and direct care staff failed to conduct the proper checks. The MAR was corrected on 12/2/2020. Team leads will be given refresher training on how to check MARs during leadership week starting 1/18/2021. |
01/22/2021
| Implemented |