Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.64(a) | In the upstairs bathroom, there were 2 used & uncovered toothbrushes sitting on top of the dusty radiator cover. | Clean and sanitary conditions shall be maintained in the home. | A shelf for the bathroom was purchased on 10/2/20 and will be affixed to the wall on 10/7/20 to place the toothbursh holders on. The toothbrushes that were found on the radiator were tossed out. New toothbrushes were purchased for each individual and placed in new toothbrush holders for each individual. Also, toothbursh covers were purchased for each individual. |
10/07/2020
| Implemented |
6400.141(a) | Individual #1 was admitted on 9/1/2020. She does not have a complete regulated physical exam in her record. The missing items include: Immunizations, Vision & hearing, Gynecological exam, Communicable disease/precautions, Health maintenance needs, Physical limitations, Information pertinent to diagnosis, and Special diet instructions. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual # 1 has an appointment for a complete physical on October 12, 2020. Independent Living LLC's physical form, which includes the missing items that are immunizations, vision & hearing, gynecological exam, communicable disease/precautions, health maintenance needs, physical limitations, information pertinent to diagnosis, and special diet instructions will be completed at the physical appointment by the physician. The Program Specialist will check to ensure that all items were completed as well. |
10/12/2020
| Implemented |
6400.211(b)(3) | There was no name, address and telephone number of the person able to give consent for emergency medical treatment in Individual #1's record. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.
| The Program Specialist is updating Individual # 1's records, including the Demographic form and the Emergency Medical Treatment Plan to include the person's contact information, including the name, address, and telephone number, to be able to give consent for emergency medical treatment. Individual # 1's ISP will be updated as well to include this information. |
10/16/2020
| Implemented |
6400.46(d) | Staff #1's CPR certification expired on 4/24/18. Staff #1 has not been recertified since then. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | Staff # 1 will be attending CPR/First Aid class which is scheduled for the agency by an American Red Cross instructor on 10/22/20. The Vice President/Program Specialist will be monitoring trainings monthly and ensuring that all staff that are coming due for their recertifications of CPR/First Aid get certified before the CPR/First Aid certification expires. |
10/22/2020
| Implemented |
6400.166(a)(2) | Individual #1's Medication Administration Record (MAR) does not list the name of the prescribing doctor. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | The Medication Administration Record was corrected to include the Name of the Prescriber by the Program Specialist/Medication Administration Instructor on 10/1/20 for Individual # 1. Also, the Program Supervisor will be monitoring the Medication Administration Log monthly to ensure that the name of the prescriber is listed. |
10/01/2020
| Implemented |
6400.166(a)(10) | The Medication Administration Record(MAR) does not list what times medications are to be administered for Individual #1. Individual #1 is prescribed the following medications with no specific time of administration: Fluoxetine HCL 20mg (1 tablet) every day; Aripiprazole 20mg (1 tablet) every day; Mirtazapine 15mg (1 tablet) every day at bedtime; and Famotidine 200mg (1 tablet) twice a day. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | The Program Specialist received written clarification of times to administer Individual # 1's medication by her prescribing doctor on 10/1/20. The Medication Administration Record was corrected on 10/1/20 by the Program Specialist. The Program Supervisor will monitor the Medication Administration Logs monthly upon delivery of her medications to ensure that they are correct. |
10/01/2020
| Implemented |
6400.166(a)(12) | Individual #1 was administered Mirtazapine 15mg and Famotidine 20mg on 9/9/2020; no times of administration were documented on her Medication Administration Record. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration. | An EIM was submitted by the CEO. All of the Direct Support Staff that work with Individual # 1 are being trained by the HCQU on 10/21/20 on proper medication administration protocols. Direct Support Staff that administered the medication on the 09/09/2020 added the time that he administered the medication to Individual # 1. The Program Specialist/Medication Instructor ensured that the Medication Administration Record was properly set up for October, 2020. The Program Supervisor will monitor the Medication Administration Record monthly to ensure that proper Medication Administration protocols are followed. |
10/21/2020
| Implemented |
6400.167(a)(4) | Medication errors are occurring due to staff administering medications outside of the 1-hour window before or after the administration time. Individual #1 receives Fluoxetine and Aripiprazole at 10am. Both of these medications were administered outside the 1-hour window on the following dates: 9/3/2020 (8am), 9/5/2020 (8:30am), 9/6-9/11/2020 (8am), 9/14/2020 (7:30am), 9/15/2020 (8am), 9/16/2020 (7am), 9/17-9/19/2020 (8am), 9/20/2020 (8:30am), 9/21-9/22/2020 (8am), 9/24-9/26/2020 (8am), and 9/28-9/29/2020 (8am). Individual #1 receives Famotidine 8am and 8:30 pm. This medication was administered outside the 1-hour window on the following dates: 9/10-9/11/2020 (10pm), 9/18/2020 (10pm), 9/23/2020 (10am) and 9/27/2020 (10am). | 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. | An EIM was submitted by the CEO on 10/01/2020 regarding all of the medication errors. The HCQU will be training all Direct Support Staff that work with Individual # 1 on 10/21/20 on proper medication administration techniques and protocols. Also, the doctor that prescribes Individual # 1's medications sent the Program Specialist written protocols which includes times of when the medication should be administered. |
10/21/2020
| Implemented |
6400.169(a) | Even though staff are trained to pass medications, they are not administering medications to Individual #1 per the department approved Medication Training Course. Individual #1 is prescribed the following medications with no specific time of administration: Fluoxetine HCL 20mg (1 tablet) every day; Aripiprazole 20mg (1 tablet) every day; Mirtazapine 15mg (1 tablet) every day at bedtime; and Famotidine 200mg (1 tablet) twice a day. None of these medications have a specific time for them to be administered. Medications are being administered at various times from day to day which is not in accordance with the Department's Medication Administration Training course. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | All staff members that administer medication to Individual # 1 will be participating in a training session with the HCQU on proper medication administration techniques including times of administration on 10/21/20. The Program Supervisor will monitor monthly that staff are following all of the protocols relating to Medication Administration. |
10/21/2020
| Implemented |
6400.186 | This home is not implementing Individual #3's Individual Support Plan (ISP). According to the ISP, sharps are kept locked at this residence. During the home inspection, licensing representatives found knives and a metal grater in an unlocked kitchen drawer and in the upstairs bathroom, 2 shaving razors were onto of the radiator cover. | The home shall implement the individual plan, including revisions. | All sharps were locked immediately following discovery of unlocked sharps. The Program Supervisor continuously monitored that they were being locked. On 10/5/20, individual # 3 chose to terminate services with Independent Living LLC and moved out of the Carey Ave home, and no other individuals in the home have a sharp restriction so the sharps are no longer kept locked at that home. On 10/09/2020, individual # 3 chose to move into another home that Independent Living LLC operates, and all sharps are kept locked at that home. The Direct Support Staff as well as the Program Specialist are continuously monitoring that the sharps are kept locked at his new home. |
09/29/2020
| Implemented |