Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.22(c) | Individual's funds shall be used for the Individual's benefit. The provider purchased a shower chair for Individual #1 on 12/04/2023 for the amount of $578.33. The Individual's representative payee, Advocacy Alliance, purchased the chair based on the request from the provider for a specific shower chair. The purchase agreement clearly stated that the chair was not returnable. At the time I visited the home on 2/05/24, the shower chair was in the box in the living room and was not usable as it was too big for the tub/shower in the individual's home, and the individual did not have a safe, usable shower chair, two months after his funds were used to make the purchase. | Individual funds and property shall be used for the individual's benefit. | The agency has reimbursed the individual for the Shower Chair and purchased a new Sliding Shower Chair. Photos sent for verification. |
02/27/2024
| Implemented |
6400.61(a) | A home serving individuals with a physical disability shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within, and exit from the home based upon the individual's needs. There was not a ramp at the rear door of the home located off the kitchen, the only other entrance to or exit from the home on the main living level. | A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have accommodations to ensure the safety and reasonable accessibility for entrance to, movement within and exit from the home based upon each individual's needs. | The agency has installed ramping at the door indicated by the inspector at the time of inspection. The agency has provided an image for verification as well. |
02/24/2024
| Implemented |
6400.61(b) | A home serving an individual with a physical disability shall have adaptive equipment necessary for the individual to move about and function in the home. At the time of the inspection, there was not a shower chair or other adaptive equipment to allow Individual #1 to bathe or utilize the only bathtub/shower in the home in a safe manner. | A home serving individuals with a physical disability, blindness, a visual impairment, deafness or a hearing impairment shall have adaptive equipment necessary for the individuals to move about and function at the home. | The agency has reimbursed the individual for the Shower Chair and purchased a new Sliding Shower Chair. Photos sent for verification. |
02/27/2024
| Implemented |
6400.67(b) | Surfaces shall be free of hazards. At the time of the inspection, the lower spigot in the bathtub was missing, exposing several inches of bare pipe which creates a potential hazard for an individual utilizing the bathtub. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The agency reinstalled the spigot the same day. Please see photo for verification. |
02/05/2024
| Implemented |
6400.165(c) | Medications shall be administered as prescribed. The medication Onelax (Bisacodyl) rectal suppositories is prescribed for Individual E.V. to be administered on a pro re nata (PRN) basis, one suppository daily as needed for constipation. According to the medication administration records for the months of December 2023 through February 8, 2024, the medication was administered every day except for two days (12/31/2023 and 1/06/2024. By administering the medication 68 of 70 days, the provider is administering the medication as a daily medication and not pro re nata, or on an as needed basis, as it was ordered by the prescriber. The medication lacosamide (Vimpat) was discontinued by the individual's neurologist on 12/28/2023 but was still listed on the January 2024 medication administration record (MAR), and staff had initialed the January MAR to indicate that the medication was administered from 1/01/2024 to 1/18/2024. **The medication blister packs for January are no longer available so it is impossible to determine if the medication was actually available and administered, or if staff just initialed the MAR without administering the medication. | A prescription medication shall be administered as prescribed. | The agency contacted the prescribing physician to rewrite the order as previously verbally directed to staff for use daily, please see documentation submitted for verification as well. |
02/12/2024
| Implemented |
6400.165(e) | The medication administration record (MAR) shall be updated as soon as written notice of a medication change is received. The medication lacosamide (Vimpat) was discontinued on 12/28/2023 by the Individual's neurologist but the January 2024 MAR shows that the medication was still listed on the MAR and staff had initialed the MAR as having administered the medication twice per day from 8:00 AM on 1/01/2024 through 8:00 AM on 1/18/2024. From 1/18/2024 at 8:00 PM through to the end of January 2024, the MAR is not initialed as though the medication has been administered, nor has the medication been discontinued on the MAR. The December 2023 MAR indicates that the medication was discontinued for the entire month of December and was not administered on any day during the month, even though documentation from the provider shows that the medication was not discontinued until 12/28/2023. | Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received. | The agency staff have been retrained to properly and promptly make the necessary changes to the MAR's and discuss the changes with every staff person in the home. |
02/12/2024
| Implemented |
6400.166(a)(11) | A medication administration record (MAR) shall be kept, including the following for each individual for whom a medication is administered: a diagnosis or purpose for the medication, including pro re nata medications. On the February 2024 MAR, the following medications do not have a diagnosis or purpose recorded: Bacitracin Ointment, Fluvoxamine tablets, Gabapentin capsules, Lorazepam tablets, Minerin Cream, Thera M tabs, Quetiapine Fumarate tablets, Guanfacine Hydrochloride tablets and Guanfacine Hydrochloride ER (extended release) tablets. | 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 Residential Director corrected the omission of information on the MAR, please see the images for further verification. |
02/05/2024
| Implemented |