Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.166(a)(10) | Individual #1's October 2022 medication record did not include the administration time for Trulicity INJ 1.5/0.5 administered on 10/5/22. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | On 10.14.22, the Director of Operations contacted the prescribing doctor and requested the documentation for administration time for this medication. As soon as the information is received, the Director of Operations will document the administration time in the individual¿s MAR. Additionally, the Director of Operations will contact the pharmacy to add the administration time in his MAR. This is expected to be complete 11.18.22 |
11/18/2022
| Implemented |
6400.166(a)(11) | Individual #1's October 2022 medication record did not include the diagnosis and purpose for Latuda Tab 20mg and Divalproex 250mg. | 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 Director of Operations reached out to the doctor for written documentation on the diagnosis/purpose for Latuda and Divalproex. The Director of Operations requested this be completed before 11.18.22. |
11/18/2022
| Implemented |
6400.167(a)(1) | Latuda 20mg., take one tablet by mouth daily prescribed to Individual #1 was not administered from 9/29/22 to 10/3/22 at 8:00AM. | Medication errors include the following: Failure to administer a medication. | The Director of Operations reported the med error on 10.14.22. The Health Director called the pharmacy on 9.29.22 to request a refill of the medication. A new medication tracking protocol has been established. The Health Director will be trained on this new protocol by 10.31.22. |
10/31/2022
| Implemented |
6400.182(c) | Individual #1's assessment, completed 4/21/22, indicates Individual #1 is able to safely use poisonous materials. Individual #1's ISP, updated 9/16/22, indicates all toxic substances are locked at the home. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The Director of Operations notified the SC on 10.14.22 to request an update to the ISP in order to reflect the current assessment. The Director of Operations will check in with the SC on weekly basis until the update is made. This documentation will be kept. The update is expected to be completed by 11.18.22 |
11/18/2022
| Implemented |
6400.207(4)(I) | Hydroxyz Pam Cap 50mg., take one capsule by mouth twice a day as needed for agitation or sleep, prescribed to Individual #1 was administered at 5:30PM on 10/1/22. The physician has not documented the well-defined descriptions of the explicit psychiatric symptoms of when to administer this medication. Reportedly, Individual #1 does not request the medication or express the need for the medication. | A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. | The Director of Operations contacted the doctor on 10.13.22 to define psychiatric symptoms. Once that information is received, staff will be trained on what a psychiatric symptom that requires this medication looks like. A PRN approval process will also be a part of this training, which is expected to occur by 11.18.22. |
11/18/2022
| Implemented |