| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.181(e)(13)(i) | The 7/11/21 assessment for Individual 1 does not address her progress over the last 365 days in any of the required areas. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| The individual's health progress was reported in the Lifetime Medical that was attached to the assessment. This was requested during the previous inspection. |
10/29/2021
| Not Accepted |
| 6400.165(g) | Individual 1 takes at least one psychotropic medication (Seroquel 10 mg to stabilize mood and reduce psychotic thoughts) and has not had a medication review at least every 3 months to review these medications. The last visits documented in the file are telehealth appointments in 8/26/20 and 12/2/20 with Dr. Rai. On the last day of the inspection immediately after the exit conference, a copy of a medication review completed 8/21/21 was provided, however it did not address the reason for prescribing the medications or the appropriate doses. In addition, no medication review was provided which shows that a review has been done between the dates of 12/2/20 and 8/21/21. | 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. | During Covid, BHID psychiatrist were conducting telehealth appointments for their quarterly evaluations. The agency attempted numerous times to have the evaluation forms completed. However, the staff were working remotely and not able to coordinate the completion of the forms. |
10/29/2021
| Not Accepted |
| 6400.169(a) | The agency did not retain documentation of staff completing medication administration training or practicum from 2020 - 2021. As it cannot be determined that staff has completed their practicum and agency training, all staff except for the agency's nurse are not permitted to administer medications until staff trainings are remediated. | 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 § 6400.162 (relating to medication administration). | Following the inspection, the agency engaged a licensed practical nurse (LPN) to administer medication. The LPN administered medication to all consumers until the staff completed the required observations. She continues to administer medication when staff hasn't completed the required training. |
10/29/2021
| Not Accepted |