| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | The February 2024 ledger has a beginning balance of $9.43. On 2/2/24 a deposit of $0.86 was made. The balance after the deposit should be $10.29 but the ledger is showing $10.91. The ending balance on the February 2024 ledger should be $99.38 but is showing $100.00. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | b. Plan of Correction
i. Plan to correct immediate problem
1. Who?
a. Matthew Williams, Operations Manager
2. What will be corrected?
a. Petty Cash will be reconciled properly
3. When and How?
a. Operations Manager corrected balance and reconciled petty cash to reflect the current correct balance in individual¿s petty cash.
b. This was completed on 3/15/2024 |
03/28/2024
| Implemented |
| 6400.77(b) | The first aid kit was missing antiseptic at the time of the inspection. | 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. | b. Plan of Correction
i. Plan to correct immediate problem
1. Who?
a. Matthew Williams, Operations Manager
2. What will be corrected?
a. Antiseptic will be placed into the First Aid Kit within the home.
3. When and How?
a. First Aid Kit was updated with Antiseptic on 3.18.2024 by Operations Manager Matthew Williams. |
03/25/2024
| Implemented |
| 6400.166(b) | The December 2023, January 2024, and February 2024 MARs for individual (AR) have numerous errors. Examples of some of the errors are as follows:
On the February 2024 MAR for individual #1 the following was found:
Carbamazepine ER 100 mg Tablet. The 2/18/24 2 pm space is initialed by staff. Note on back of form indicates visit with parents at that time and that meds will be given by parents. The RCG for this regulation states the following:
The administration of a medication by a source outside of the home (such as a monthly scheduled injection in a physician's office or medication administered while visiting family) should not be documented on the medication record for the home. Only medication given by staff members of the home are to be documented on the medication record.
Zinc 50 mg Tablet. The 2/1/24 8 am space is initialed by staff and the 2/4/24 space is initialed by staff. The notes on the back indicate No supply available no meds given. However, on 2/3/24 the space is initialed by staff but there is not note to indicate no supply was available. No initials are present for 2/2/24 and no note is provided as to why medication was missed.
Vitamin E 400 unit Softgel. The 2/2 8 am space is blank and there is no documentation on the back of form to indicate why.
On the December 2023 MAR for individual #1 the following was found:
There were duplicate lines for Carbamazephine Er 100 mg and according to Faithful Homes staff, this was due an employee reentering the medication in error. However, on 12/8/23 staff initialed for the 8 pm dose on both lines which indicates it was given twice. Staff initialed both lines on 12/9/23 and 12/10/23 at 8 am, 2 pm, and 8 pm again indicating double dose was given 3 times that day.
On the January 2024 MAR for individual #1 the following was found:
The entire day on 1/27/24 is without initials and there is no note to indicate what occurred.
Carbamazephine Er 100 mg 1/4/24 2 pm, 1/14/24 2 pm, and 1/28/244 8 am are blank indicating no medication was given | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | o Plan of Correction
Plan to correct immediate problem
Who?
o Derek Shive, Executive Director
What will be corrected?
o All medication errors will be entered into the EIM System by 3/26/2024.
When and How?
o All medications will be entered into the EIM System by 3/26/2024 |
03/28/2024
| Implemented |