Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.62(a) | Individual #1 is not safe around poisonous materials. At the time of the 2/2/22 inspection, there was a bottle of Palmolive dish detergent and a bottle of Method hand soap by the kitchen sink and various bottles of powder and lotions in a caddy beside the bathroom sink. These products are required to be locked in this home when not actively in use. | Poisonous materials shall be kept locked or made inaccessible to individuals. | 1) Plan to Fix the Immediate Problem
a. WHO: House Manager took all products not in use and placed them in the Cleaning Supply Closet after inspection was completed.
b. WHAT: All cleaning supplies/bathroom supplies that are considered poisonous materials were placed back into the cleaning supply closet. |
02/18/2022
| Implemented |
6400.141(c)(4) | Individual #1's 5/26/20 and 5/25/21 annual physicals indicate that the physician was "unable to perform" hearing and vision exams. There are no records maintained that Individual #1 has had a completed hearing or vision exam. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | 1) Plan to Fix the Immediate Problem
a. WHO: Operations Manager will schedule both a hearing exam (ENT) and vision exam (Optometrist) for the individual to have these exams completed.
b. WHAT: These appointments will ensure that individual has an up to date hearing and vision exam. |
04/06/2022
| Implemented |
6400.141(c)(6) | Individual #1 had a tuberculin test on 8/19/19 and not again until 12/29/21. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | 1) Plan to Fix the Immediate Problem
a. WHO: Program Specialist caught error prior to licensing but still was overdue by 4 months. Tuberculin test was completed/read on 12/29/2021.
b. WHAT: Program Specialist corrected non-compliance by getting Tuberculin test completed for individual on 12/29/21.
c. WHEN/HOW: Tuberculin test was completed on 12/29/2021. |
02/08/2022
| Implemented |
6400.165(c) | Individual #1 has a PRN prescription for acetaminophen that is to be administered, "every 4 hours as needed for pain." On 9/2/21 and 9/3/21, this medication was administered for the reason of "running nose." | A prescription medication shall be administered as prescribed. | 1) Plan to Fix the Immediate Problem
a. All medication administration records were reviewed on 2/9/2022 to ensure no other errors in administration occurred throughout agency in relation to regulation 165(c). No other issues found at this time. |
02/18/2022
| Implemented |
6400.166(a)(11) | There is no diagnosis or purpose listed on Individual #1's Medication Administration Record for the following medications: clobazam, vimpat, and omeprazole. | 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. | 1) Plan to Fix the Immediate Problem
a. Contacted providers and received updated orders instructing on diagnoses/purposes completed on 2/14/2022. |
02/18/2022
| Implemented |
6400.167(a)(1) | The following medications were not administered to Individual #1 at 8pm on 7/25/21: topiramate, divalproex, vimpat, clobazam, melatonin.
Individual #1 did not receive their 8am dose of clobazam on 11/20/21 and their 8pm dose of clobazam on 11/21/21.
Individual #1 did not receive their 12am dose of divalproex on 11/26/21. | Medication errors include the following: Failure to administer a medication. | 1) Plan to Fix the Immediate Problem
a. All medication errors were reviewed and ensured they were reported. |
02/18/2022
| Implemented |
6400.167(b) | There is no documentation maintained that the failure to administer Individual #1's 8pm medications on 7/25/21 was reported as a medication error. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | 1) Plan to Fix the Immediate Problem
a. This medication error was reported on the EIM system on 2/2/2022 after it was identified as an error by the Executive Director. |
02/18/2022
| Implemented |
6400.167(c) | The failure to administer Individual #1's 8pm medications on 7/25/21 was not reported as an incident in the department's incident management system. | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | 1) Plan to Fix the Immediate Problem
a. Incident reported onto the EIM system on 2/2/2022 by Executive Director. |
02/18/2022
| Implemented |
6400.181(f) | Individual #1's 2020 ISP meeting was conducted on 12/4/20. Their assessment was not sent to the plan team until 11/6/20. Individual #1's 2021 ISP meeting was conducted on 12/3/21. Their assessment was not sent to the plan team until 11/5/21. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | 1) Plan to Fix the Immediate Problem
a. Reviewed all other assessments to ensure compliance with other assessments within Faithful Homes. |
02/18/2022
| Implemented |