Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.81(k)(6) | There was no mirror present in Individual #1's room at time of inspection | In bedrooms, each individual shall have the following: A mirror. | A ¿shatter-proof¿ mirror has been purchased, see attachment labeled Mirror invoice 09.30.21¿. Individual has behavioral management issues that result in severe property destruction. A typical mirror would not be safe as it would be smashed and become a safety risk for individual JS. Please see attachment labeled ¿JS Mirror Email SC¿ for communication to Individual Supports Coordinator informing them of the ¿shatter-proof¿ mirror. |
10/08/2021
| Implemented |
6400.163(g) | Individual #1's Hytone Hydrocortisone cream 2.5% not found at site at time of inspection. | Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions. | PRN Hydrocortisone was removed from individual medication list, see attachment labeled Med List & Doctors¿. Individual dermatologist recommended discontinuation, see attachment labeled PS Note 9.15.21¿. |
09/15/2021
| Implemented |
6400.166(a)(6) | The medication list for Individual #1's did not include the dosage form for the following medications:
- Tavaborole Solution 5%
- Prevident 5000 -- 100ML | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | Individual medication list was revised to include dosages for the two medications in question. Please see attachment labeled Med & Doctor¿s List¿. |
09/19/2021
| Implemented |
6400.166(a)(10) | There are several instances of medications having only the frequency listed rather than the administration time on Individual #1's Medication list. The following did not have times listed:
-Celexa -- 30mg -- QD
-Calcium and Vitamin D -- 600MG & 200MG -- BID
-Centrum -- 1 Tab -- BID
-Tavaborole Solution -- Apply to affected area once daily
Ammonium Lactate 12% cream -- listed as BID on med list but listed as 8am on bottle | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | Individual medication list was revised to include administration time for the five medications in question. Please see attachment labeled Med & Doctor¿s List¿. |
09/19/2021
| Implemented |