| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6500.109(d) | The written fire drill record for the fire drills held on 1/14/2022, 7/30/2021 and 10/30/2021 did not address problems encountered. This section was left blank. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the smoke detector was operative. | Fire drills held on 1/14/2022, 7/30/2021 and 10/30/2021 were reviewed with the life sharing provider and the problems encountered section was completed on 4/15/2022. The provider has been retrained on filling out the form entirely. |
05/01/2022
| Implemented |
| 6500.121(c)(7) | Individual #1's most recent gynecological examination was completed on 5/13/2019. | 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. | Gynecologist appointment was cancelled due to Covid in 2020, then rescheduled and she was sick. It is now scheduled for June 23,2022 at 11:15 with Dr. Wendy Steffl.
Provider on regulation of gynecological exam. Also, trained the provider on obtaining written documentations of cancelled or reschedule appointments. |
06/23/2022
| Implemented |
| 6500.45(a) | Life Share Provider #1 was trained in first aid and Heimlich techniques on 4/20/2018 and then again on 6/19/2020. | The primary caregiver shall be trained by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid and Heimlich techniques prior to an individual living in the home and annually thereafter. | CPR will be completed with in the agency by CPR trainer. Life sharing provider added to human resources CPR tracker as of 4/19/2022. Life sharing provider will be retrained by 6/19/2022. |
04/19/2022
| Implemented |
| 6500.136(a)(4) | Individual #1 is prescribed Albuterol Sulfate HFA 108mcg/Act Aer Pras with directions to inhale two puffs by mouth every six hours as needed for wheezing. The name of the medication was not listed on Individual #1's April 2022 Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | MAR logs have been updated with name of medication for prescribed Albuterol Sulfate HFA 108mcg/Act Aer Pras as of 4/15/2022.. Provider retrained on MAR logs. |
05/01/2022
| Implemented |
| 6500.136(a)(5) | Individual #1 is prescribed Albuterol Sulfate HFA 108mcg/Act Aer Pras with directions to inhale two puffs by mouth every six hours as needed for wheezing. The strength of the medication was not listed on Individual #1's April 2022 Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | MAR logs have been updated with strength of medication for prescribed Albuterol Sulfate HFA 108mcg/Act Aer Pras as of 4/25/2022. Provider retrained on MAR logs. |
05/01/2022
| Implemented |
| 6500.136(a)(6) | Individual #1 is prescribed Albuterol Sulfate HFA 108mcg/Act Aer Pras with directions to inhale two puffs by mouth every six hours as needed for wheezing. The dosage form of the medication was not listed on Individual #1's April 2022 Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | MAR logs have been updated with dosage form for prescribed Albuterol Sulfate HFA 108mcg/Act Aer Pras as of 4/15/2022. Provider retrained on MAR logs. |
05/01/2022
| Implemented |
| 6500.136(a)(7) | Individual #1 is prescribed Albuterol Sulfate HFA 108mcg/Act Aer Pras with directions to inhale two puffs by mouth every six hours as needed for wheezing. The dose of the medication was not listed on Individual #1's April 2022 Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | MAR logs have been updated with dose of medication for prescribed Albuterol Sulfate HFA 108mcg/Act Aer Pras as of 4/15/2022. Provider retrained on MAR logs |
05/01/2022
| Implemented |
| 6500.136(a)(8) | Individual #1 is prescribed Albuterol Sulfate HFA 108mcg/Act Aer Pras with directions to inhale two puffs by mouth every six hours as needed for wheezing. The route of administration of the medication was not listed on the April 2022 Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | MAR logs have been updated with route of administration for prescribed Albuterol Sulfate HFA 108mcg/Act Aer Pras as of 4/15/2022. MAR log is typed and saved for use monthly. Provider retrained on MAR logs. |
05/01/2022
| Implemented |
| 6500.136(a)(9) | Individual #1 is prescribed Albuterol Sulfate HFA 108mcg/Act Aer Pras with directions to inhale two puffs by mouth every six hours as needed for wheezing. The frequency of administration of the medication was not listed on Individual #1's April 2022 Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | MAR logs have been updated with frequency of administration for prescribed Albuterol Sulfate HFA 108mcg/Act Aer Pras as of 4/15/2022. MAR log is typed and saved for use monthly. Provider retrained on MAR logs. |
05/01/2022
| Implemented |
| 6500.136(a)(11) | Individual #1's April 2022 Medication Administration Record did not have the diagnosis or purpose for the following medications: Levothyroxine Sodium, Loratadine, Polyethylene Glycol, Senexon, Ondansetron and Albuterol Sulfate. | 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. | MAR logs have been updated for all medication¿s, Levothyroxine Sodium, Loratadine, Polyethylene Glycol, Senexon, Ondansetron and Albuterol Sulfate with a Diagnosis or purpose for the medication, including pro re nata on 4/15/22. Life sharing coordinator and provider reviewed MAR logs with diagnosis listed and filled in correctly. MAR logs are typed and saved for use. Provider retrained on MAR logs. |
05/01/2022
| Implemented |
| 6500.139(a) | Life Share Provider #1's most recent Medication Administration training was completed on 1/18/2020. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6500.132 (relating to medication administration). | Life Sharing provider completed training on April 23, 2022 and training tracking form updated to include Medication Administration training. |
04/23/2022
| Implemented |