| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.181(d) | On 8/7/2023, Individual #1's assessment, dated 6/10/2023, was not signed by the Program Specialist. | The program specialist shall sign and date the assessment. | The Annual Assessment was signed. We will complete a quarterly audit to look over the current assessments. During this audit will ensure that signatures are completed. [Additional information provided by the agency via email on 10/24/23: Program Specialist and Director will conduct quarterly audits of individual assessments to ensure signatures are part of the assessment. Documentation of quarterly audits will be maintained. DPOC by HSKP, HSLS, on 11/1/2023]. |
08/10/2023
| Implemented |
| 6400.165(b) | Individual #1's Clonidine Tab 0.2mg, with the instructions "Take one tablet by mouth twice a day for impulse disorder" dated 5/25/2023 is the correct prescription; however, 3 blister packs being stored with Individual #1's current medications contained pharmacy labels that stated "Take 1 tablet by mouth three times a day for blood pressure" dated 10/10/2022. | A prescription order shall be kept current. | The outdated medication has been removed from the site. A proper prescription received. Staff are required to be Med Trained before their ability to pass medication to consumers. Current OCS staff have been reoriented and trained on how to properly complete the Medication Administration Record (MAR) as of 8/29/23. Staff members who are not completing MAR correctly will have Med administration responsibilities revoked until retraining and observation from the training specialist. [Additional information provided by the agency via email on 10/24/23: Medications with pharmacy labels indicating a previous order were removed from the home on or about 8/9/23. Monthly audits of Medication Administration Records (MARs) by the House Managers, Program Specialists, and Director are being documented. Daily checks of MARs are not being documented. Weekly checks of MARs are being documented. The agency anticipates transitioning to electronic MARs on or about 11/1/23. DPOC by HDKP, HSLS, on 11/1/2023]. |
08/10/2023
| Implemented |
| 6400.166(a)(13) | On 8/8/2023, Individual #1's August 2023 Medication Administration Record (MAR) was missing name and initials of the person administering medications, on 8-1-2023 and 8-2-2023 for all daily medications at 8:00am and 8:00pm including, but not limited to: Buspirone Tab 10mg, Clonidine Tab 0.2mg, Divalproex Tab 500mg, Gavilax Powder, Metformin Tab 500mg, and Vitamin D Tab 1000unit. On 8/8/2023, Individual #1's August 2023 Medication Administration Record (MAR) was missing name and initials of the person administering Metformin Tab 500mg at 8:00am on 8-1-23, 8-2-2023, 8-3-2023, 8-4-2023, and 8-5-2023. | 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. | Staff are required to be Med Trained before their ability to pass medication to consumers. As a result, staff who are not Med Trained will not be allowed to pass medication to consumers. Current OCS staff have been reoriented and trained on how to properly complete the Medication Administration Record (MAR) as of 8/29/23. Staff members who are not completing MAR in its entirety will have Med administration responsibilities revoked until retraining and observation from the training specialist. [Additional information provided by the agency via email on 10/24/23: Daily Checks of the MAR are not being documented. Weekly checks of the MARs are being completed and documented. The agency anticipates transitioning to electronic MARs on or about 11/1/23. DPOC by HDKP, HSLS, on 11/1/2023]. |
08/29/2023
| Implemented |
| 6400.166(d) | Individual #1 is prescribed SF 5000 Plus cream 1.1% with instructions to use in place of toothpaste. This medication was not administered as prescribed on 8/1/2023 through and including 8/8/2023, as the medication was not available in the home. Individual #1 is prescribed Melatonin Tab 3mg; however, the medication was not administered as prescribed on 8/7/2023 at 8:00pm. | The directions of the prescriber shall be followed. | We contacted the doctor to send in the discontinued script to PDC pharmacy. This medication is discontinued and not a current medication. It has been discontinued on the MAR. [Additional information provided by the agency via email on 10/24/23: The agency verified with the ordering physician that the toothpaste medication was discontinued on 8/9/23. The clonidine medication was updated to include a pharmacy label with the current prescription order. Daily checks of the Medication Administration Records (MARs) is not being documented. Weekly checks of MARs are being completed and documented. The agency anticipates transitioning to electronic MARs on or about 11/1/23. DPOC by HDKP, HSLS, on 11/1/2023]. |
08/29/2023
| Implemented |
| 6400.213(1)(i) | On 8/7/2023, Individual #1 record did not include weight or identifying marks. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. (ii) The race, height, weight, color of hair, color of eyes and identifying marks. | The OCS management team has reviewed the demographic information for all clients. We have placed an N/A in any space in which we do not have a comment. This review will happen twice a year to make sure no blanks are on the demographic sheets. [Additional information provided by the agency via email on 10/24/23: Demographic information for Individual #1 was updated on 8/28/23. Documentation of the audit of all individual demographic data was not documented. Audits of individual demographic data will be completed twice a year by the Program Specialist and Director. Documentation of the audits will be maintained. DPOC by HDKP, HSLS, on 11/1/2023]. |
09/05/2023
| Implemented |