Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.67(a) | There were areas of disrepair in the home:
- There was water damage under the bathroom sink from an apparent leak.
- A knob was missing from the dresser in the individual's bedroom,
- The handle on the freezer was broken off. | Floors, walls, ceilings and other surfaces shall be in good repair. | The dresser knob, freezer handle and and bathroom sink leakage were all replaced and repaired. |
11/11/2023
| Implemented |
6400.113(c) | Annual Fire Safety was not located in Individual 1's binder. Documentation was requested but not received during inspection. | A written record of fire safety training, including the content of the training and a list of the individuals attending, shall be kept. | Person Centered Services will ensure all staff are trained on fire-safety and ensure we are in compliance with the 24 hour annual training requirement and new employee orientation. |
11/15/2023
| Implemented |
6400.141(c)(4) | For Individual 1, No vision screening and hearing screening was performed on annual physical dated 10/27/23. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | The insurance company of individual 1 would not approve another physical until the 2024. We have however, notified individual 1's PCP of this violation. The PCP acknowledged the oversight and promised to complete annual physicals that meets the regulations compliance, going forward. |
11/15/2023
| Implemented |
6400.141(c)(6) | On Individual 1's annual physical dated 10/27/23, TB exam was dated for 10/27/23, but results were not listed as read negative anywhere else in binder. | 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. | The insurance company of individual 1 would not approve another physical until the 2024. We have however, notified individual 1's PCP of this violation. The PCP acknowledged the oversight and promised to complete annual physicals that meets the regulations compliance, going forward |
11/15/2023
| Implemented |
6400.141(c)(10) | On Individual 1's annual physical dated 10/27/23, Free from communicable diseases was not checked. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | The insurance company of individual 1 would not approve another physical until the 2024. We have however, notified individual 1's PCP of this violation. The PCP acknowledged the oversight and promised to complete annual physicals that meets the regulations compliance, going forward |
11/15/2023
| Implemented |
6400.24 | The controlled substances in the home were not being counted accurately. For individual 1 there were 22 Clonazepam tablets listed on the count, however 44 were present in the home. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | The additional counts of Clonazepam tablets were returned to the pharmacy for disposal. |
11/11/2023
| Implemented |
6400.52(a)(1) | The training hours for Staff 1 were less than the required 24hrs, based on the reported calendar training year (2022 being assessed). | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | In the next training circle, PCS Inc. will ensure full compliance with the Regulations for a 24 hour training hours for all employee per their functions. |
11/20/2023
| Implemented |
6400.163(h) | Individual 1's Divalproex 500MG was discontinued however the blister packs containing the medication were still present in the medication box. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | PCS returned the discontinued medication to the pharmacy |
11/20/2023
| Implemented |
6400.165(c) | The dose on the individual 1's Quetiapine dose did not match between the blister pack and the medication administration log. The MAR stated to take one 100MG tablet twice a day, however the MAR stated to take one and a half of those tablets. | A prescription medication shall be administered as prescribed. | Our RN contacted our pharmacy and the error on the MAR was since corrected, per the PCP instructions. |
02/16/2024
| Implemented |
6400.165(g) | Individual 1 was admitted on 12/18/22, however, the psychotropic med reviews on file were for 11/1/23 and for 10/23/23. We need to see at least quarterly reviews with psychiatrist signature assessing levels when taking psychotropic meds. There were several copies of 8/8/22, however that was from 14 months prior. | 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. | Due to intense behavior issues, appointments of Individual 1 kept being pushed forward and thus the violation. Individual one has since calmed a little bit. Appointments with physicians are much manageable now. |
11/20/2023
| Implemented |
6400.166(b) | For individual 1, The PRN medications that were present in the medication box and reported as active by the staff were not listed on the MAR. Those PRN medications were:
- Docusate Sodium 100 MG cap -- Take one capsule by mouth once daily as needed.
- Meloxicam 15 MG -- Take one tablet by mouth once daily as needed
- MAPAP Arthritis ER 650 MG -- Take one tablet by mouth every 6 hours as needed for mild pain, moderate pain, or headaches for up to 10 days. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | All PRN medications not reauthorized by the PCP were returned to the Pharmacy. We have since constituted a check to ensured actual medication are in agreement with the MAR |
11/20/2023
| Implemented |