| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | The agency indicated on their 1/20/23 self-inspection tool that quarterly psychiatric medication reviews are not completed timely for Individual #1. At the time of the 5/9/23 inspection, the agency did not record their plan of correction for the violations self-identified on the 1/20/23 tool. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| All future self assessments will contain plan of correction if there are self identified citations and will be maintained in our records for at least one year. This will be over seen by the service director who oversees 6400 homes. |
06/02/2023
| Implemented |
| 6400.110(e) | This home has 5 floors including the attic and basement. The smoke detectors on each floor are not interconnected. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | Interconnected alarms were installed by maintenance department the day of exit. |
06/02/2023
| Implemented |
| 6400.165(c) | REPEAT from 5/17/2022 annual inspection: On March 24, 2023, Individual #1 was prescribed Doxycycline 100mg twice daily for 5 days. Staff initialed the individual's March 2023 medication administration records (mars) at 8am and 8pm on the following days as administering the medication: 3/24-3/31, 8 total days.
On 10/21/2022, the individual was prescribed Cephalexin 500mg, take 1 capsule every 12 hours for 7 days. Staff documented that Individual #1 was administered Cephalexin for 11 days: 8am and 8pm from October 21st-31st.
Individual #1 is to be administered Ferrous Sulfate 325mg, 1 tablet on Mondays, Wednesdays, and Fridays at 8am. On Sunday, May 7, 2023, staff administered Ferrous Sulfate 325mg. This was administered on the wrong day. | A prescription medication shall be administered as prescribed. | All coordinators and program specialist were retrained with a refresher course on time limited medications and how to record at their management team meeting on 5/17/23. All employees are being retrained on time sensitive medications at next house meetings. coordinator or specialist will record initial entry on MAR for time sensitive medications until employees receive trainings. |
08/31/2023
| Implemented |
| 6400.167(a)(1) | REPEAT from 5/17/2022 annual inspection: Individual #1 is prescribed Lithium Carbonate ER 300mg, take 3 tablets at bedtime for anxiety. Staff did not administer the medication from 4/19/23 to 4/21/2023 due to the medication not being available in the home.
On May 9, 2023, Individual #1 did not receive their Metformin ER 500mg at 4pm and Melatonin 10mg at 8pm. The individual's medication administration records (mars) were blank.
On May 10, 2023, Individual #1 was not administered Ferrous Sulfate 325mg. The Mar was blank. | Medication errors include the following: Failure to administer a medication. | The employee who made this error had already terminated employment. All other team members will be retrained as part of the refresher course on medication administration, medication errors and reporting to coordinator or on call when medication is not available. |
08/31/2023
| Implemented |
| 6400.167(c) | The medication errors reported in 6400.165(c), and 167(a)(1) of this report, were not reported as incidents as specified in 6400.18(b) and investigated. | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | All medication errors have been reported. Team members have been retrained on immediate reporting for medication errors. |
08/31/2023
| Implemented |