| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | On 3/04/2024 at 4:18pm, upon departing the home, the front door to the home was slammed shut and Program Specialist #2 was heard yelling "This is why I put notes on all of the medications" and "You're all getting written up for this". Individual #1 and Individual #2 were both present in the living room upon departure of the home, were present during the incident. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | Upon discovery of the incident, provider entered an incident in EIM for each of the individuals (9387163, 9387183) in order to commence an investigation for psychological abuse. |
04/08/2024
| Implemented |
| 6400.66 | On 3/04/2024 at 3:52pm the front room, on the basement level of the home, did not have any lighting. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| On 4/16/2024 a new light fixture was installed by the maintenance team. |
04/16/2024
| Implemented |
| 6400.70 | On 3/04/2024 the telephone located in the living room was not operable. The only other telephone in the home was located locked in the staff office not easily accessible to the individuals. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| The phone located in the LR was in need of being charged due to the Individual utilizing it frequently and not replacing it. Provider recharged the phone on 3/4/ 2024 by placing the handset on the base. Provider also moved the second phone out of the staff office and into the dining room to make more accessible. |
03/05/2024
| Implemented |
| 6400.101 | On 3/04/2024 there was a dead bolt lock on the basement side of the garage door, and a keypad and key lock on the inside of the garage, and no exit from the garage to the outside of the home. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| Maintenance visited the home upon discovery of this violation on 3/4/24 and removed the lock creating access in and out of that area and eliminating any egress issues. |
03/08/2024
| Implemented |
| 6400.110(e) | On 3/04/2024 smoke detectors tested at 4:16pm, were not interconnected, and the home has three stories. | 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. | Maintenance visited the home on 3/4/2024 and ensured that the detectors on all 3 stories were interconnected. Following this, all drills were functioning properly and interconnected, |
03/04/2024
| Implemented |
| 6400.18(b)(2) | Individual #1 is prescribed Valacyclovir 500mg, this medication was last administered on 3/1/2024 at 8:00 AM. This medication was initialed as administered from 3/02/2024 through 3/04/2024 at 8:00 AM but had not been present in the home since 3/1/2024 due to not receiving a refill of the medication. As of 4/4/2024 this has not been reported through the Department's information management system. | 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. | Provider entered the incident into EIM (9400004) in order to report the error. |
04/08/2024
| Implemented |
| 6400.163(h) | On 3/04/2024 Individual #1's following medications in the home were expired: Ibuprofen expired 12/02/2023, Pain Reliever Plus expired December 2023, Acetaminophen expired February 2024. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Medications were removed from the home and brought into the AMP office to be destroyed. A medication disposal form was completed for each medication disposed. Medications were reordered on 3/4/2024 and received from the pharmacy on 3/5/204. |
04/01/2024
| Implemented |
| 6400.166(a)(11) | Individual #1's March 2024 medication administration record did not include a diagnosis or purpose for the following medications: Ferrous Sulfate 325mg, Valacyclovir 500mg, and Urea Lotion 40%. Individual #2's March 2024 medication administration record did not include a diagnosis or purpose for Trospium 20mg. | 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 was corrected with any missing information on 3/4/2024. Program Supervisor reached out to pharmacy to address the issue and ensure that the diagnosis is included on the MAR. Team Leads were retained on 4/1/2024 on proper procedure for reviewing MARs when they are received including all necessary items that must be documented on the MAR. |
04/01/2024
| Implemented |
| 6400.166(a)(13) | Direct Service Worker #1 administered Individual #1's 8:00am medications on 3/04/2024. Individual #1's March 2024 medication administration record did not include Direct Service Worker #1's name. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | Supervisor reached out to direct staff person and instructed them to sign the MAR upon arrival for shift that evening. |
04/01/2024
| Implemented |
| 6400.166(a)(15) | On 3/4/2024 Individual #2's March 2024 medication administration record did not include special precautions to crush medications. Individual #2's assessment completed 1/02/2024 states the individual prefers the medications to be crushed and administered with applesauce. Individual #2's individual support plan, last updated 3/01/2024, states the individual needs the medications crushed for administration and prefers to take them crushed in applesauce. On 3/08/2024 the agency received documentation from Individual #2's physician indicating that the individual's medications should be crushed and administered at their scheduled times. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Special precautions, if applicable. | Provider Supervisor reached out to medical providers that prescribe medications and requested that each order reflect that they are to be crushed so that this can be reflected on the MAR. Medical and Psychiatric providers are currently sending this documentation into the pharmacy so that this can be reflected on the MAR. |
04/01/2024
| Implemented |
| 6400.167(a)(1) | Individual #1 is prescribed Valacyclovir 500mg, this medication was last administered on 3/1/2024 at 8:00 AM. This medication was initialed as administered from 3/02/2024 through 3/04/2024 at 8:00 AM but had not been present in the home since 3/1/2024 due to not receiving a refill of the medication. As of 4/4/2024 this has not been reported through the Department's information management system. | Medication errors include the following: Failure to administer a medication. | Medication was received on 3/5/2024. There were no further omissions following the discovery of the omissions listed above. Program Specialist completed a medication audit on 3/5/2024 to ensure that all medications were present. |
03/05/2024
| Implemented |
| 6400.182(c) | Individual #1's assessment, completed 5/11/2023, states the individual is able to use and avoid poisons. Individual #1's individual support plan, last updated 2/12/2024, states the individual "requires line-of-sight supervision while cleaning products are out and being used. The individual requires verbal direction to use cleaning products correctly and safely". | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Program Specialist updated the assessmentn4/1/24 to include " requires line of sight supervision while cleaning products are out and being used." |
04/01/2024
| Implemented |