Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.107 | At 10:30AM, a portable space heater was in the closet in Individual #1's bedroom. | Portable space heaters, defined as heaters that are not permanently mounted or installed, are not permitted in any room including staff rooms.
| The portable space heater was removed from Individual #1¿s residence on 3/28/22 by the Program Specialist and returned to the office. Individual #1¿s mother made arrangements to have the space heater returned to her. |
03/28/2022
| Implemented |
6400.181(e)(10) | Individual #1's assessment, completed on 9/15/2021, does not address lifetime medical history. This section says, "N/A." | The assessment must include the following information: A lifetime medical history. | The Program Specialist will be responsible for ensuring provider¿s annual assessments include a lifetime medical history. If there is a vacancy with the Program Specialist position. The Sr. Director will assume responsibility for ensuring the annual assessment includes a lifetime medical history.[Immediately, the program specialist will complete the lifetime medical history for Individual #1 and all other individuals in the community homes. Over the next 2 weeks, the Sr. Director shall review all individuals' current assessment to ensure all required information is included in all individuals' current assessment. (DPOC by AES,HSLS on 5/4/2022)] |
04/11/2022
| Implemented |
6400.181(e)(11) | Individual #1's assessment, completed on 9/15/2021, does not include psychological evaluations. This section says, "N/A." | The assessment must include the following information: Psychological evaluations, if applicable. | The Program Specialist will be responsible for ensuring the annual assessments will include a psychological evaluation, when applicable. Beginning 5/1/22 and re-occurring for each annual assessment completed afterwards. If there is a vacancy with the Program Specialist position. The Sr. Director will assume responsibility for ensuring the annual assessment includes a psychological evaluation.[Immediately, the program specialist will obtain a psychological evaluation for Individual #1 and all other individuals in the community homes, as required. Over the next 2 weeks, the Sr. Director shall review all individuals' current assessment to ensure all required information is included in all individuals' current assessment. (DPOC by AES,HSLS on 5/4/2022)] |
05/01/2022
| Implemented |
6400.32(r)(1) | Individual #1 would like to exercise the right to lock her bedroom door. The agency has not provided Individual #1 a mechanism for Individual #1 to lock and unlock her bedroom door. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | By 4/27/22 The Office Administrator will submit the maintenance request for the bedroom door of Individual #1 to provide a mechanism to lock and unlock the door. [Immediately, the CEO or designee will ensure Individual #1's right to lock and unlock Individual #1's bedroom door is provided. Immediately, the CEO or designee with ensure all individual in community homes are exercising their right to lock and unlock their bedroom doors and maintain documentation. Immediately, the CEO or designee shall educate all staff person the individual right to lock and unlock and their responsibilities to ensure this right. Documentation of the training and responsibilities shall be kept. (DPOC by AES,HSLS on 5/4/2022)] |
04/27/2022
| Not Implemented |
6400.166(a)(4) | Individual #1 is prescribed Naproxen Tab 500mg. The March 2022 Medication Administration Record does not include the name of the medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | The provider is actively searching for an LPN/RN who will be responsible for monitoring of all medication and medical administration records. The hiring process is expected to be completed by 5/15/22. The LPN/RN will verify that all medications include the name of the medication by completing a weekly monitoring of medication and medical administration records for each home. If a medication does not have the name of the medication, the LPN/RN will contact the pharmacy to provide the name of the medication. Until the LPN/RN position if filled, the Lead Supervisors will be responsible for monitoring all medication and medical administration records. |
05/30/2022
| Not Implemented |
6400.166(a)(5) | Individual #1 is prescribed Naproxen Tab 500mg. The March 2022 Medication Administration Record does not include the strength of the medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | The provider is actively searching for an LPN/RN who will be responsible for monitoring of all medication and medical administration records. The hiring process is expected to be completed by 5/15/22. The LPN/RN will verify that all medications include the strength of the medication by completing a weekly monitoring of medication and medical administration records for each home. If a medication does not have the strength of the medication, the LPN/RN will contact the pharmacy to provide the strength of the medication. Until the LPN/RN position if filled, the Lead Supervisors will be responsible for monitoring all medication and medical administration records. |
05/30/2022
| Not Implemented |
6400.166(a)(6) | Individual #1 is prescribed Naproxen Tab 500mg. The March 2022 Medication Administration Record does not include the dosage form of the medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | The provider is actively searching for an LPN/RN who will be responsible for monitoring of all medication and medical administration records. The hiring process is expected to be completed by 5/15/22. The LPN/RN will verify that all medications include the dosage form of the medication by completing a weekly monitoring of medication and medical administration records for each home. If a medication does not have the dosage form of the medication, the LPN/RN will contact the pharmacy to provide the strength of the medication. Until the LPN/RN position if filled, the Lead Supervisors will be responsible for monitoring all medication and medical administration records. |
05/30/2022
| Not Implemented |
6400.166(a)(7) | Individual #1 is prescribed Naproxen Tab 500mg. The March 2022 Medication Administration Record does not include the dose of the medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | The provider is actively searching for an LPN/RN who will be responsible for monitoring of all medication and medical administration records. The hiring process is expected to be completed by 5/15/22. The LPN/RN will verify that all medications include the dose of the medication by completing a weekly monitoring of medication and medical administration records for each home. If a medication does not have the dose of the medication, the LPN/RN will contact the pharmacy to provide the dose of the medication. Until the LPN/RN position if filled, the Lead Supervisors will be responsible for monitoring all medication and medical administration records. |
05/30/2022
| Not Implemented |
6400.166(a)(8) | Individual #1 is prescribed Naproxen Tab 500mg. The March 2022 Medication Administration Record does not include the route of administration. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | The provider is actively searching for an LPN/RN who will be responsible for monitoring of all medication and medical administration records. The hiring process is expected to be completed by 5/15/22. The LPN/RN will verify that all medications include the route of administration by completing a weekly monitoring of medication and medical administration records for each home. If a medication does not have the route of administration, the LPN/RN will contact the pharmacy to provide the route of administration. Until the LPN/RN position if filled, the Lead Supervisors will be responsible for monitoring all medication and medical administration records. |
05/30/2022
| Not Implemented |
6400.166(a)(9) | Individual #1 is prescribed Naproxen Tab 500mg. The March 2022 Medication Administration Record does not include the frequency of administration. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | The provider is actively searching for an LPN/RN who will be responsible for monitoring of all medication and medical administration records. The hiring process is expected to be completed by 5/15/22. The LPN/RN will verify that all medications include the frequency of administration by completing a weekly monitoring of medication and medical administration records for each home. If a medication does not have the frequency of administration, the LPN/RN will contact the pharmacy to provide the frequency of administration. Until the LPN/RN position if filled, the Lead Supervisors will be responsible for monitoring all medication and medical administration records. |
05/30/2022
| Not Implemented |
6400.166(a)(11) | Individual #1 is prescribed Naproxen Tab 500mg. The March 2022 Medication Administration Record does not include the diagnosis or purpose of the medication. | 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. | The provider is actively searching for an LPN/RN who will be responsible for monitoring of all medication and medical administration records. The hiring process is expected to be completed by 5/15/22. The LPN/RN will verify that all medications include the diagnosis or purpose of the medication. If a medication does not have the diagnosis or purpose of the medication, the LPN/RN will contact the pharmacy to provide the diagnosis or purpose of the medication. Until the LPN/RN position if filled, the Lead Supervisors will be responsible for monitoring all medication and medical administration records. |
05/30/2022
| Not Implemented |
6400.166(c) | Individual #1 refused prescribed medication, Sucralfate, from March 16, 2022 through March 19, 2022 at 8:00AM and March 16, 2022 through March 24, 2022 at 8:00PM. The provider does not have documentation of the providers notification of the individual's refusal to take the medication and the prescriber's response. | If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual. | By 4/27/22 All ACHC staff who administer medications will receive training that will cover refusal of medication. The training will include how to document the refusal on the medication record and how to document the report to the prescriber. The report to the prescriber will require an e-mail. The sent e-mail will serve as documentation of the requirement to notify the prescriber of the refusal or if there is harm to the individual. Until the LPN/RN position if filled, the Lead Supervisors will be responsible for monitoring all medication and medical administration records. |
05/30/2022
| Not Implemented |
6400.167(a)(1) | Sucralfate prescribed to Individual #1 was not administered on 3/22/2022 and 3/23/2022 at 8:00PM. | Medication errors include the following: Failure to administer a medication. | The provider is actively searching for an LPN/RN who will be responsible for weekly monitoring of all medication and medical administration records. The hiring process is expected to be completed by 5/15/22. The LPN/RN will verify that all medications have been administered and documented. Any incident of failure to administer medication will be reported in the EIM system within 24 hours and corrective action will be developed and issued. Until the LPN/RN position if filled, the Lead Supervisors will be responsible for monitoring all medication and medical administration records. |
05/30/2022
| Not Implemented |
6400.167(c) | Individual #1 was not administered a prescribed medication on 3/22/2022 and 3/23/2022. This medication error was not reported in the Enterprise Incident Management system as of 3/25/2022 at 4:00PM. | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | The medication error was reported in the Enterprise Management System on March 25, 2022, after discovery. |
03/25/2022
| Not Implemented |