| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.101 | Hydroxyls 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. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| the Maintenance Director removed the coded keypad that led to the garage on 10.5.22. The Maintenance Director also switched out the doorknob to the top of the stairs. |
10/05/2022
| Implemented |
| 6400.162(a) | Direct Service Worker #1 administered Clonazepam Tab 0.5 mg., take one tablet by mouth twice a day to Individual #1 at 8:00AM on 10/3/22. Direct Service Worker #1 medication administration training expired on 8/14/22 and reportedly has been administering medications since August 2022. | A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication. | On 10.4.22, The Direct Service Worker was informed she is no longer permitted to administer medication. The Director of Operations completed Med Admin Train the Trainer training on 10.13.22 and will re-train the Direct Service Worker by 11.18.22 |
11/18/2022
| Implemented |
| 6400.166(b) | Clonazepam Tab 0.5 MG, take 1 tablet by mouth twice a day, prescribed to Individual #1 was not initialed as administered at 8:00AM on 10/5/22. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The staff who failed to initial the MAR will be retrained by 11.18.22 on proper MAR documentation. |
11/18/2022
| Implemented |