| 6400.112(c) | The written fire drill record for the fire drills conducted 6/25/2021 and 7/31/2021 did not include whether the smoke detectors were operative. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | August 10th 2021: The fire drill documentation will be updated with specific details/instructions on how to completely and accurately complete the document to prevent inaccuracies and to ensure each section is completed in its entirety. Additionally, the documentation will be updated to denote if the fire alarm activated was operable at the time of the drill. |
08/16/2021
| Implemented |
| 6400.166(a)(11) | Individual #1's July 2021 Medication Administration Record does not include diagnosis or purpose for the following medications: Clonazepam, Novolog OG Mix Flexpen, Trazodone and Aspirin. Individual #2's July 2021 Medication Administration Record does not include diagnosis or purpose for the following medications: Risperidone, Docusate Sod Cap and Cetirizine. | 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. | August 10th 2021: The Medication Administration Record (MAR) used by our agency will be updated to include the diagnosis/purpose for each medication taken by Individual #1 and Individual #2. [August 2021 MARs for Individual # and Individual #2 were updated to include diagnosis for each medication. At least monthly, the program specialist and/or program director shall audit all individual MARs to ensure all required information is included. Documentation of audits shall be kept. (DPOC by AES,HSLS on k8/23/2021)] |
08/16/2021
| Implemented |