| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | Self-Assessment was to be completed between 1/14/21 to 6/24/21 and was not completed until 7/8/21. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| A tracking system has been developed to ensure that self assessments are completed 3-6 months prior to expiration date of the agency's certificate of compliance |
07/26/2021
| Implemented |
| 6400.62(a) | The following poisons were unlocked throughout the home: Windex, Floor Cleaner (2 bottles), and Carpet Cleaner. In addition, the poison closet was unlocked at the time of the inspection. The individual in this home is not safe around poisonous materials. | Poisonous materials shall be kept locked or made inaccessible to individuals. | All staff are being retrained on keeping poisons locked. The respite coordinators will do random checks of their houses, ensuring that poisons are locked as needed |
07/27/2021
| Implemented |
| 6400.143(a) | Individual #1 is to have a daily weight check as their weight is a current medical concern. It is documented on Individual #1's weight chart that Individual #1 frequently refuses to be weighed. There is no documentation regarding the continued attempts to train the individual on the need for this medical care. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | The task of providing education to the individual has been assigned to the respite coordinator. She will provide education or ask the nurse to attempt to provide education each month. The respite coordinator will complete a service note every time training is completed. |
07/30/2021
| Implemented |
| 6400.144 | Individual #1's eating plan prescribed by the doctor on 3/30/21 indicates that the individual should remain upright after eating for 45 minutes. BOLD's eating and feeding plan for Individual #1 dated 5/23/21 indicates that individual should stay sitting up for 5 minutes after eating. | 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.
| Program specialist and service director are creating a new document to capture all daily documentation that is needed for this individual. The team believes this will be easier to complete all data collection when everything is on one page. |
08/06/2021
| Implemented |
| 6400.151(b) | Staff #2's most recent physical exam, dated 3/19/21 was not dated by the physician. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | HR has created a check list for physical exams to use when physicals are returned to us from the doctor. This checklist will be used every time a staff person has their physical to ensure that it has been filled out correctly. |
07/27/2021
| Implemented |
| 6400.181(e)(9) | Individual #1's assessment dated 6/23/21 does not include documentation of the individual's disability, including functional and medical limitations. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | The program specialist is adding functional/medical limitation information into the assessment for all respite individuals including this person. She will ensure all updates to assessment are completed quickly and it will be reviewed by the service director. |
07/31/2021
| Implemented |
| 6400.18(b)(2) | The failure to administer medications to Individual #1 on 5/23/21 and 5/24/21 was not reported as a medication error. | 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 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | A HCSIS report has been filed for missed medication. The team is being retrained on incident reporting standards. Respite coordinator will ensure that MAR checks are completed weekly to catch any errors. Disciplinary action will be taken for errors not reported in a timely manner. |
08/06/2021
| Implemented |
| 6400.166(a)(2) | Individual #1's Medication Administration Records do not include the prescriber name for any listed medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | The MAR has been revised to include name of prescriber in each block. Implementation for new MAR will begin August 1, 2021 |
08/01/2021
| Implemented |
| 6400.166(a)(11) | Individual #1's Medication Administration Records do not include the diagnosis or purpose for the following medications: Quetiapine Fumarate 100mg, Quetiapine Fumarate 50mg, Omeprazole 20mg, Clonazepam 1mg, Benztropine .5mg, Carbidopa-levodopa 25-100, Clonidine .1mg, escitalopram 5mg, and Trazodone 50mg. | 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. | The MAR has been updated to include a spot in each block for the diagnosis. These new forms will be in place for August 1, 2021 |
08/01/2021
| Implemented |
| 6400.167(a)(1) | Individual #1 did not receive their 8am dose of Quetiapine Fumarate 100mg on 5/23/21 and 5/24/21 as the medication had run out and was not available in the home. | Medication errors include the following: Failure to administer a medication. | A HCSIS report has been filed for missed medication. The team is being retrained on incident reporting standards. Respite coordinator will ensure that MAR checks are completed weekly to catch any errors. Disciplinary action will be taken for errors not reported in a timely manner. |
08/06/2021
| Implemented |
| 6400.167(b) | There is no documentation present indicating that the prescriber was notified that Individual #1 did not receive their 8am doses of Quetiapine Fumarate 100mg on 5/23/21 and 5/24/21. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | During individuals medication review appointment on 7/26/21, the doctor was notified of the error and in the future, any missed doses should be given as soon as possible as long as it is less than 2 hours before next medication time. Documentation of this recommendation will be faxed to the doctor's office for his signature. |
07/27/2021
| Implemented |