| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | There was a large hole in the wall next to the door located in Individual #1 bedroom. | Floors, walls, ceilings and other surfaces shall be in good repair. | Individual #1 has a a history of property destruction as seen throughout the apartment. When upset individual will punch and throw things to cause property damage. The maintenance department does try to work as quickly as possible to repair damages caused by individual #1. Repair to the wall was completed on 11/4/21. Please see attachment #12. |
11/04/2021
| Implemented |
| 6400.72(b) | There was a hole in the screen located in the living room the size of a softball. (No work order was provided at time of inspection). | Screens, windows and doors shall be in good repair. | The individual has a history of property destruction. The hole in the screen was caused by the individual throwing a rock through the window in a attempt to hit staff. The hole in the screen was repaired on 11/4/21. Please see attachment #12. Work order history show that the screens has been previously repaired due to the individuals' destruction. Building maintenance work as quickly as possible to make repairs. |
11/04/2021
| Implemented |
| 6400.77(b) | The First Aid Kit did not contain Tweezer. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | Tweezers were present inside of the First Aid Kit and may have been overlooked. Please see attachment #13. |
11/01/2021
| Implemented |
| 6400.77(c) | The First Aid Kit did not contain a first aid manual. | A first aid manual shall be kept with the first aid kit. | The First Aid Kit contains a "First Aid Guide". Please see attachment #12. To avoid confusion, a "First Aid Manual" has been added to the site. Please see attachment #14. |
11/02/2021
| Implemented |
| 6400.144 | During the inspection it was observed that unknown medication (two pills) was in the medication box out of the medication blister pack and/or medication packaging. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| The medication (two pills) in the medication box outside of its packaging ,may have been done in human error. The medication was immediately discarded of. Please see attachment #16. Agency has updated the Daily Med Count sheet to include checking the medication box to be free from debris and/or lose medication. It is the responsibility of staff and supervisor to ensure that no medication that is outside its original packaging. |
11/05/2021
| Implemented |
| 6400.162(b)(1) | Staff #1 is administering medication and has not completed a Department-approved medication administration course. | A prescription medication that is not self-administered shall be administered by one of the following: A licensed physician, licensed dentist, licensed physician's assistant, registered nurse, certified registered nurse practitioner, licensed practical nurse, licensed paramedic or other health care professional who is licensed, certified or registered by the Department of State to administer medications. | Staff #1 does not give medication. At the time of inspection staff #1 was awaiting observation as part of the Medication Administration before becoming Med-certified. In the absence of a qualified staff to give medication, proper arrangements are made in advance to have a qualified or licensed person administer medications. The agency makes every effort to have staff med trained within one month of hire. While the pandemic has made this difficult, the agency has come up with a schedule that will allow med-certification classes at minimum once a month. This will allow more staff to become med certified at a faster rate. |
11/12/2021
| Implemented |
| 6400.163(h) | Medication ALBUTEROL HFA Inh. (PRN), is listed on the (MAR) Medication Administrative Record as DISCONTINUED but in Individuals #1 medication box. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Medication Albuterol was immediately removed from the medication box on 11/1/21. Please see attachment #16.
Agency has updated the Daily Med Count sheet to include that all discontinued and expired mediations are removed from the Medication Box and properly discarded with the nurse. Please see attachment #17. |
11/01/2021
| Implemented |
| 6400.165(b) | Medication OXCARBAZEPINE 600mg Tab for Individual #1 could not be located during inspection but was noted to be administered from 10/01/21 thru 10/27/21. | A prescription order shall be kept current. | Oxcarbazepine was contained in a separate zip lock located in the medication box. Please see attachment #19. The medication as now been included in the medication bundle of the applicable medication time (e.g. 8am, 12pm, 4pm, 8pm, etc) Meds being bundled together allow for less incidents during med administration. appropriate Initials/codes for dates 10/28-10/31 have been added this was an oversight on administering staff. Staff have been retrained on proper documentation of the medication administration process. |
11/01/2021
| Implemented |
| 6400.165(c) | It could not be determined if the medication for Individual #1 is being administered as prescribed, the (MAR) Medication Administrative Record was not being completed by the staff administering the medication. The MAR was not completed from 10/27/21 till 10/31/21. At time of inspection there was no MAR for November 2021. | A prescription medication shall be administered as prescribed. | During the time of inspection, Nurse had removed original copies of MAR, to file and copy. Agency has added a copy machine to the nearby site so that MAR copies can be immediately made and returned to the book immediately. Both the site and office must maintain a copy of all MAR'S and should not be removed from program books. Original MAR's has been returned to site Med book. |
11/05/2021
| Implemented |
| 6400.165(c) | Medication CHLORPROMAZINE 100mg Tab are not being administered as prescribed for Ind. #1 | A prescription medication shall be administered as prescribed. | Chlorpromazine 100mg was discontinued on 9/6. please see attachment #20. Individual #1 is currently not taking this medication and is not on the MAR. The Chlorpromazine has been removed from the medication box and discarded. |
11/01/2021
| Implemented |
| 6400.166(b) | On the (MAR) Medication Administrative Record it indicated that Individual #1 is to check his (BLOOD PRESSURE DAILY) it could not be determined based on documentation if this is being conducted as prescribed. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | A sperate sheet for blood pressure checks is located in the front of the MAR book due to the MAR not allowing enough space for proper documentation. Please see attachment #21. During a 11/2/21 ISP meeting, it was added that individual #1 is able to check his blood pressure himself as it promotes independence. This is something that the individual does without reminder and it is important to him. Log has been moved from the front of the book and one is placed for each month inside the MAR so that documentation is more clear. |
11/02/2021
| Implemented |