| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(c) | The written fire drill record for the fire drill held 8/19/19 did not include the amount of time it took for evacuation. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | - The immediate response was to have the staff that completed the fire drills make the corrections that were in violation. In response to the annual inspection, it was noted that a team lead position needed to be created. The team lead position was created, and staff were identified and trained on the position. The team lead position will report directly to the program director. One of the areas to be addressed by the team lead was the supervision of direct care staff completing monthly fire drills. The monthly fire drill form has been revised to draw attention to all areas of concern. All staff will be retrained on the form. Once a fire drill has been completed it will be reviewed by the team lead for any errors and then passed onto the program director for review. Both the team lead and the program director will sign off on the fire drill form to verify that it has been reviewed. All staff will be trained on the fire drill form by September 20th ,2019. Along with the cited regulation.Quarterly fire drill book audits will occur to monitor for effectiveness.[Documentation of the trainings shall be kept. (DPOC by AES,HSLS on 9/18/19)] |
09/30/2019
| Implemented |
| 6400.165(g) | The review of medications prescribed to treat symptoms of a psychiatric illness, dated 4/19/19 for Individual #2 did not include the necessary dosage or the need to continue the medications. The review of medications prescribed to treat symptoms of a psychiatric illness, dated 3/11/19 for Individual #2 did not include the necessary dosage of the medications. | 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. | The immediate response was to send the forms back to the doctor's office for correction's. All attempts will be documented . To prevent this type of occurrence in the future, the medical form has been revised. Inresponse to the annual inspection a team lead position has been created. The team lead position will be under the program director. The team lead will be responsible for the initial review of all appointment forms prior to submission to the program director. Once a form has been reviewed without any errors it will than be placed in the individual file . all staff will be trained on the new process along with any new staff being hired. Quarterly audits of all individual file will occur to monitor for effectiveness. [Documentation of audits of medication reviews, individual record and trainings shall be kept. (DPOC by AES,HSLS on 9/18/19)] |
09/30/2019
| Implemented |
| 6400.166(a)(7) | Refresh tear drop 0.5%, instill two drops into each eye every morning is prescribed to Individual #1. Individual #1's August 2019 Medication Administration Record reads "instill one to two drops in left eye every morning." | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | In response to violation. The immediate correction was that the violation was reviewed with the staff that work at the site. Staff will pass the medication as per the prescribed order. To prevent this type of error in the future all staff will receive a medication review class. The medication review class will consist of reviewing comparing medication labels to the Medication administration record, what to do in the event something doesn¿t match. Along with what to do if an individual refuse a medication. A medication refusal form has been created along with a revised med error form. As a response to the annual inspection, agency is putting team lead staff in place. One of the responsibilities of the team lead staff will be to assist the program director with monitoring the medications. The team lead will be trained to be medications observers. The team lead staff will monitor the medication process with the direct care staff. Medication records will be monitored weekly by the Team lead staff and monthly by the program director. A weekly Medication record review tool has been created to assist the team lead staff when reviewing the medication administration record. The program director will complete a medication review monthly with the team lead. All agency staff will receive training by September 30, 2019. The Team lead staff will receive the observer training according to the guidelines specified on the my ODP website by October31,2019. [Documentation of trainings shall be kept. (DPOC by AES,HSLS on 9/18/19) |
10/31/2019
| Implemented |
| 6400.166(a)(10) | Hydroxyzine HCL 25mg, take 2 tablets (50mg) by mouth at bedtime and an additional 1 to 2 tablets once a day as needed for anxiety is prescribed to Individual #2. Individual #2's August 2019 Medication Administration Record reads "take 1 to 2 tablets by mouth every night at bedtime as needed for anxiety." | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | In response to violation. The immediate correction was that the violation was reviewed with the staff that work at the site. Staff will pass the medication as per the prescribed order. To prevent this type of error in the future all staff will receive a medication review class. The medication review class will consist of reviewing comparing medication labels to the Medication administration record, what to do in the event something doesn¿t match. Along with what to do if an individual refuse a medication. A medication refusal form has been created along with a revised med error form. As a response to the annual inspection, agency is putting team lead staff in place. One of the responsibilities of the team lead staff will be to assist the program director with monitoring the medications. The team lead will be trained to be medications observers. The team lead staff will monitor the medication process with the direct care staff. Medication records will be monitored weekly by the Team lead staff and monthly by the program director. A weekly Medication record review tool has been created to assist the team lead staff when reviewing the medication administration record. The program director will complete a medication review monthly with the team lead. All agency staff will receive training by September 30, 2019. The Team lead staff will receive the observer training according to the guidelines specified on the my ODP website by October31,2019.[Documentation of trainings shall be kept. (DPOC by AES,HSLS on 9/18/19) |
10/31/2019
| Implemented |