| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.144 | Individual #1 was scheduled for an ENT appointment in November 2021 and Faithful Homes was not able to produce verification if this appointment was completed or offered.
Faithful Homes is to document Individual #1's behaviors on the daily service notes by putting a tally mark for each incident the individual has of verbal aggression, physical aggression, property destruction, and self-injurious behavior. From March 2021 to February 2022 there were a total of 291 days that no daily service logs were provided. Of the daily service logs that were provided, there were 13 shifts that the questions were not completed regarding Individual #1 exhibiting behaviors. | 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.
| a. Plan to fix immediate problem
i. Who is responsible for correcting?
1. Operations Manager
2. Program Manager
3. Program Specialist
ii. What will be corrected?
1. ENT appointment was completed on 4/11/2022 and is recommended to be completed yearly.
2. Service Notes are unable to be corrected due to time since notes were overdue, corrective action will address this.
iii. When and HOW?
1. Immediate Corrections have been completed. |
07/22/2022
| Implemented |
| 6400.165(g) | Individual #1 was due for a quarterly medication review in September and December of 2021 and Faithful Homes was not able to produce verification if these appointments were completed or offered. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | a. Plan to fix immediate problem
i. Who is responsible for correcting?
1. Operations Manager
2. House Manager
3. Program Specialist
ii. What will be corrected?
1. Psych med review was completed on 4/7/2022. Next appointment is scheduled for 7/5/2022 to be back on cycle for quarterly med reviews.
iii. When and HOW?
1. Immediate corrections have been completed. |
07/22/2022
| Implemented |
| 6400.166(d) | Individual #1 is prescribed Lorazepam 0.5 mg every four hours as needed for severe anxiety, aggression, or if aggressive, not to exceed 2mg daily. From July 2021 to March 2022, individual #1 was administered said medication incorrectly, 11 times. | The directions of the prescriber shall be followed. | a. Plan to fix immediate problem
i. Who is responsible for correcting?
1. Executive Director
ii. What will be corrected?
1. Medication Errors will be put into the EIM System for the 11 occurrences by end of business day on 6/21/2022.
2. PRN Protocol has been created and approved by ODP Representative as well as ISP Team including the Behavior Support Specialist. This was completed and staff were trained on this on 5/12/2022.
iii. When and HOW?
1. Medication errors have been reported on the EIM System on 6/21/2022.
2. Training on PRN Protocol for Lorazepam Use was completed with staff on 5/12/2022. |
05/12/2022
| Implemented |
| 6400.167(c) | Individual #1 is prescribed Lorazepam 0.5 mg every four hours as needed for severe anxiety, aggression, or if aggressive, not to exceed 2mg daily. From July 2021 to March 2022, individual #1 was administered said medication incorrectly (given prior to the four-hour window), 11 times. None of these instances were reported as an incident as specified in 6400.18b. | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | a. Plan to fix immediate problem
i. Who is responsible for correcting?
1. Executive Director
ii. What will be corrected?
1. Medication errors will be entered for the 11 medication errors that were not reported in the EIM System.
iii. When and HOW?
1. All medication errors will be reported by end of business on 6/21/2022 into the Incident Management System. |
07/22/2022
| Implemented |
| 6400.207(4)(I) | Individual #1 is prescribed Lorazepam 0.5 mg every four hours as needed for severe anxiety, aggression, or if aggressive, not to exceed 2mg daily. Individual #1 was administered said medication on the following dates without supporting documentation that medication was needed:
7/13/21; 9/21/21 at 515pm & 715pm; 3/20/22 at 6pm & 7pm; 3/21/22 at 6pm & 7pm; 3/22/22 at 815am, 915am, 615pm & 915pm; 3/23/22 at 520am, 620am, 6pm & 7pm; 3/24/22 at 640am, 740am, 1230pm & 130pm; 3/25/22 at 9am, 2pm, 3pm.
Administering this prescription without verification that individual #1 was displaying aggression, being aggressive or showing signs of severe anxiety is considered a chemical restraint. | A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition. | a. Plan to fix immediate problem
i. Who is responsible for correcting?
1. Executive Director
ii. What will be corrected?
1. Protocol has been put into place to ensure that documentation is completed if the use of a PRN is required.
iii. When and HOW?
1. Training on the PRN use and supplemental documentation (PRN Behavior Tracking) was completed on 5/12/2022.
2. ISP/BSP are also updated to include this information. |
07/01/2022
| Implemented |