| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.43(b)(3) | The CEO did not unsure safety of individual #1 and #2 due to, the noon medications for individual #1 and #2 were not administered while licensing was in the home from 1pm to 2:40pm. The staff did not have qualifications to administer the medications, and a nurse did not come to administer the medications, also no one called the physician to see if they should administer or not. This needs to be reported as neglect, and no report was submitted. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. | The current CEO was not in place during the inspection visit of 11/27/23. The interim CEO, from 10/17/23 - 11/29/23, was not aware of any regulations since she was not qualified. As of 11/30/23, the current CEO is qualified and well aware of the 6400 regulations regarding the responsibilities of the CEO. The current CEO will ensure the safety and protection of the individuals by re-training the staff on all aspects of medication administration. |
12/31/2023
| Not Implemented |
| 6400.43(b)(4) | The CEO is not incompliance with this chapter due to, the noon medications for individual #1 and #2 were not administered while licensing was in the home from 1pm to 2:40pm. The staff did not have qualifications to administer the medications, and a nurse did not come to administer the medications, also no one called the physician to see if they should administer or not. This needs to be reported as neglect, and no report was submitted. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Compliance with this chapter. | Referring back to violation #1, the nurse who was contracted to dispense medication on this particular day - failed to do so. Therefore, this nurse has been terminated and it is now the responsibility of the staff that are medication trained. In addition to the staff on the premises, the CEO and program specialist are also medication trained and available to dispense medications. An incident of neglect has been filed in the EIM for both individuals and a certified investigation in currently in progress. |
12/31/2023
| Not Implemented |
| 6400.112(d) | Individuals are not able to evacuate the building to a safe place within 2 1/2 minutes as indicated on the fire drill reporting forms. Also, the agency conducts fire drills without sounding alarms. When sounding the alarm at Apt B the individuals did not know what the sound was and did not move until instructed. Illustrating that the alarm is not being used during fire drills.
(A drill was conducted on 11/27/2023, there was not enough staff to complete the drills which was timed and exceeded 4 minutes, staff reported they do not and have never utilized the Hoyer Lift for either individual) | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | All staff that work in this home shall be trained in using the Hoyer Lift by date. Staff who work with individuals in wheelchairs shall be trained in emergency evacuating procedures to evacuate them using a med-sled or fireman's carry by 3/18/2024. [DIRECTED PLAN 2/26/2024] |
03/18/2024
| Not Implemented |
| 6400.144 | Medication BACLOFEN 20mg for Individual #1 is not being administered as prescribed for the 12pm dosage, as there is no qualified person to give this medication at this time.
(Licensing left the facility at 2:40pm and the medication was not administered)
Prescribed medication BACLOFEN 20mg and PROPRANOLOL HCL 10mg for Individual #2 is not being administered as prescribed for the 12pm dosage, as there is no qualified person at the facility to administer the medication at this time. The nurse who was hired was not present an hour before or after administering time.
(Licensing left the facility at 2:40pm and the medication was not administered) | 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.
| it is apparent that individual 1's skills may need to be reevaluated. We will discuss with the team in regard to changing the ISP to better reflect individual 1's current capabilities. This discussion occurred on 12/11/23 with individual 1's SC and it was determined by the team to change the ISP to reflect that they need meds to
be administered by trained staff. When new admissions occur with self-administering individuals the agency will complete a self-administering competence and assessment to ensure they can complete self-administration. This will be reviewed by management when doing onsite visits. [DIRECTED PLAN 2/26/2024] |
03/18/2024
| Not Implemented |
| 6400.18(a)(5) | The noon medications for individual #1 and #2 were not administered while licensing was in the home from 1pm to 2:40pm. The staff did not have qualifications to administer the medications, and a nurse did not come to administer the medications, also no one called the physician to see if they should administer or not. This needs to be reported as neglect, and no report was submitted. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Neglect.
| Staff will be re-trained to notify management of any delay in the disbursement of medication. This will take place during an Inservice by 03/18/2024 with a variety of other topics for best practices. This training will be included in the new hire's orientation for incoming staff. [DIRECTED PLAN 2/26/2024] |
03/18/2024
| Not Implemented |
| 6400.32(c) | The noon medications for individual #1 and #2 were not administered while licensing was in the home from 1pm to 2:40pm. The staff did not have qualifications to administer the medications, and a nurse did not come to administer the medications, also no one called the physician to see if they should administer or not. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | After this incident, the agency nurse was contacted to assess the health of the individuals. After examining the individuals, the nurse determined that their was no harm done by missing the dose of medication and therefore notifying the prescriber was not necessary. |
12/31/2023
| Not Implemented |
| 6400.162(a) | Both units Apt. A and Apt B staff are administering medications. No verification was provided (staff stated no training was given) that medication administration training was completed or trained by a trainer. | 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. | Previous management was allowing non-trained staff to deliver medications occasionally. On the date of the unannounced visit by licensing, there was a medication trained staff member, but his credentials were not verified because management did not know where they were physically located. Once the current CEO resumed his role, these documents were provided to licensing and the county and were verified, so that this staff is now providing meds for both A/B. |
12/31/2023
| Not Implemented |
| 6400.165(b) | Prescribed medication BROMPHEN/DM for Individual #2 is not kept current, medication is not in the med box but on the MAR. | A prescription order shall be kept current. | This PRN medication was expired and was awaiting refill from the pharmacy. At this time, the medication will be refilled. |
12/04/2023
| Not Implemented |
| 6400.167(a)(4) | The noon medications for individual #1 and #2 were not administered while licensing was in the home from 1pm to 2:40pm. The staff did not have qualifications to administer the medications, and a nurse did not come to administer the medications. | Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time. | The nurse who was contracted to dispense medication on this particular day - failed to do so. Therefore, this nurse has been terminated and it is now the responsibility of the staff that are medication trained. Currently there are 2 DSP staff that are medication certified and 2 administrative staff that are medication certified. These staff will work together in coordinating the proper administration of medications. |
12/31/2023
| Not Implemented |
| 6400.167(d)(3) | The noon medications for individual #1 and #2 were not administered while licensing was in the home from 1pm to 2:40pm. The staff did not have qualifications to administer the medications, and a nurse did not come to administer the medications, also no one called the physician to see if they should administer or not. | A medication error shall be reported to the prescriber under any of the following conditions: If there is harm to the individual. | After this incident, the agency nurse was contacted to assess the health of the individuals. After examining the individuals, the nurse determined that their was no harm done by missing the dose of medication and therefore notifying the prescriber was not necessary. |
12/31/2023
| Not Implemented |