| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.111(a) | There was not fire extinguisher in the basement of the home. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | The immediate response was to purchase a new fire extinguisher. The receipt and a picture will be sent in for verification. To prevent reoccurrence of this violation in the future, Team Lead positions have been created. The team lead staff will be responsible to complete a fire drill monthly with the staff. The fire drill form will consist of a section to assure fire extinguishers are present. The Program Director will meet with the Team lead staff twice a month to review completion of the fire drill form to assure compliance. Quarterly fire drill book audits will be completed to monitor for accuracy. [Aforementioned picture and receipt provided to the department on 9/17/19. Upon opening a new home, the CEO or Designee shall audit the self inspection document to ensure compliance with regulations and the document is completed correctly prior to signing and swearing the information is true and correct. (DPOC by AES,HSLS on 9/18/19)] |
09/30/2019
| Implemented |
| 6400.163(h) | Tretinoin 0.05% cream prescribed to Individual #1 was discontinued on 6/19/19 and remained in Individual #1's the medication storage box. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | 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 October 31,2019. [Discontinued medication, Tretinoin 0.05% cream was disposed of by the program director on 8/24/19. Within 60 days of receipt of the plan of correction, the CEO or designee shall train all staff persons certified to administer medications on the agency's discontinuation of medications policy and procedures to ensure prescription medications that are discontinued or expired are disposed of in a safe manor according to Federal and State statutes and regulations. Documentation of the training shall be kept. Documentation of disposal of medications shall be kept. (DPOC by AES,HSLS on 9/19/19)] |
10/31/2019
| Implemented |
| 6400.166(b) | Guanfacine tab 1mg take one tablet by mouth twice a day AM and 3:30PM for ADHD prescribed for Individual #1 was not documented as administered from 8/1/19 to 8/22/19 at 3:30PM. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | 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(d) | Individual #1 is prescribed Guanfacine tab 1mg take one tablet by mouth twice a day Am and 3:30PM for ADHD. There is not documentation of administration for the 3:30PM dose for the month of August. | The directions of the prescriber shall be followed. | 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 |