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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(6) | TB test results were not provided for Individual #1. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Comment:
Individual #1¿s had a TB test completed on September 12, 2020, and said document was submitted as part of the licensing documents, labeled R6_Physical and TB. It is admitted that the TB was completed and noted on a different document other than the annual physical document.
Correction ¿ Immediate Cure (Exhibit I)
WHO:
Residential Director
Compliance Specialist
Nurse
House Manager, upon hire
WHAT:
We need to ensure that each Individual under our care receives a tuberculin skin test by Mantoux method every two years.
HOW:
Individual #1 re-did his TB test. We then forwarded the information to his primary care physician, and asked the primary care physician to complete another annual physical form, and transcribe the results of the TB onto the annual physical form. The doctor has agreed to return the completed documents to Providence Corporation by July 2, 2021. We also reviewed other Individuals¿ annual physicals to ensure compliance. In addition, we re-trained the Residential Director, Nurse and Compliance Specialist so that they will not accept an annual physical form that does not have TB portion completed, even if said information is attached to the annual physical. The training was completed on June 22, 2021. When we hire a House Manager, the House Manager will receive the same training. |
07/10/2021
| Implemented |
| 6400.166(a)(11) | The following medications in Individual 1's March 2021 Medication Administration Record (MAR) lacked a corresponding diagnosis or reason for prescribing the medication: Amphetamine 30mg ER Capsule, Pantoprazole 40mg Tablet, Ammonium Lactate Lotion 12%, Losartan 50mg, Fluticasone 50mg, Fiber-Lax 625mg Tablet, Furosemide 20mg, Bupropion 300 ER, Multivitamin, Vitamin D 2000 IU, Reguloid 0.52gm Capsule, Topirimate 25mg, Methylphenidate 10mg, Advair Diskus 250/50, Clonidine 0.2mg Tablet, Aripiprazole 30mg Tablet, Haloperidol 10mg Tablet, Senna Plus 8.6/50mg Tablet, Benztropine 1mg Tablet, Aquaphor Ointment, Metformin 750mg, Trazodone 300mg Tablet, Acetaminophen 500mg Tablet, Banophen 50mg, Loratadine 10mg, and Cephalexin Cap 500mg. Those same medications, in addition to the following medications, lacked a corresponding diagnosis or reason for prescribing the medication in Individual 1's April 2021 MAR: Methylprednisone Dose Pack and Clindamycin HCL 300mg Capsule. | 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. | Comment:
We need a change in policy. The corresponding diagnosis and reason for prescription is usually memorialized on the Medication List, not the Medical Administration Record as a way to conserve space on the MAR.
Correction ¿ Immediate Cure (Exhibit II)
WHO:
Residential Director
Nurse
Compliance Specialist
House Manager, upon hire
WHAT:
We need to ensure that there is a readily available information related to the diagnosis and/or purpose of each prescribed medication.
HOW:
A change in recording procedure was needed. Therefore, we immediately changed the information being recorded on the MAR for all the Individuals. We now include each diagnosis and/or purpose of medication, with each recording on the MAR. The MAR is created by the Residential with supervision from the Nurse and Compliance Specialist. Therefore, we re-trained the Residential Director, Nurse and Compliance Specialist. The training occurred on June 22, 2021. When we hire a House Manager, the House Manager will receive the same training. |
06/22/2021
| Implemented |
| 6400.166(b) | The 8 pm administration for Cephalexin Cap 500mg on 03/29/2021 was not initialed by staff in Individual 1's Medication Administration Record (MAR). | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Correction ¿ Immediate Cure (Exhibit III)
WHO:
Residential Director
House Manager, upon hire
Nurse
Staff
WHAT:
We need to ensure all medication are recorded in the MAR at the time the medication is administered.
HOW:
We re-trained all the staff who are certified to give medication. We also re-trained the Nurse, Residential Director and Compliance Specialist so that they are more careful while reviewing the MAR. The Nurse, Residential Director and Compliance Specialist were re-trained on June 22, 2021. Staff were re-trained between June 17, 2021 and June 25, 2021. When we hire a House Manager, the House Manager will receive the same training. |
07/05/2021
| Implemented |
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