Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.111(c) | The fire extinguisher in the kitchen was 1A-10-BC rating. | A fire extinguisher with a minimum 2A-10BC rating shall be located in each kitchen. The kitchen extinguisher meets the requirements for one floor as required in subsection (a). | The fire extinguisher was replaced that same day and the quality insurance will complete a weekly check. |
04/05/2018
| Implemented |
6400.141(c)(15) | Individual #1's annual physical examination dated 6/7/17 did not include special diet instructions. | The physical examination shall include:Special instructions for the individual's diet. | On 2/28/2018 individual #1 physical was corrected by the PCP. The new program specialist will check to always make sure all information is filled out completely. |
04/05/2018
| Implemented |
6400.161(e) | Portia-28 prescribed for Individual #1 was discontinued but was not disposed of. Medication was still in the medication box. | Discontinued prescription medications shall be disposed of in a safe manner. | Medication was removed from individual #1 med box an discarded. The quality insurance will check all medication on a weekly basis. The medication was taken back to the pharmacy of a plan of corrections. |
04/05/2018
| Implemented |
6400.163(c) | There was no documentation to show that Individual #1's Psychiatric medications were reviewed for the period 11/23/17 and 1/23/18. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | on Feb 18, 2017 the consumer had her med review and also on May 7th she had another medication review. Agape's new program specialist will compete documentation on all medication reviews. |
05/09/2018
| Implemented |
6400.167(b) | Individual #1's medication review reveals that Chlorpromoziho 100mg was not at administered 4/1/18 at 5pm. The medication was still in the medication box. | Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Individual #1 medications was disposed of, the medication was corrected on the Mar, the staff was trained on the 6400 167(b) regulation on giving meds on the correct time the medication should be administered. The quality insurance will check meds on a weekly basis. |
04/04/2018
| Implemented |