| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | On 3/24/2023, the light in the ceiling in the basement of the home did not have a ceiling panel cover. There was a door knob size hole behind the door in Individual #1's bedroom. | Floors, walls, ceilings and other surfaces shall be in good repair. | Maintenance Supervisor completed a maintenance request and the repairs were completed by Maintenance Technician on the same day. (Please note that the damage occurred approximately 1 hour prior to the inspection ¿¿) |
03/24/2023
| Implemented |
| 6400.112(c) | The written fire drill records for fire drills, held on 1/13/23 and 2/19/23, did not include problems encountered. | 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. | On 3/24/23 Maintenance Supervisor updated the LHC Fire drill form to include ¿Problems Encountered¿ and was made available to all service locations. All homes then completed a fire drill using the updated form on or before 3/31/23. |
03/31/2023
| Implemented |
| 6400.112(d) | The fire drill, held on 1/13/23 at 9:44 PM, had an evacuation time of 2 minutes and 41 seconds. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | Maintenance Supervisor revised the Fire Drill form to include a section to describe problems encountered during fire drills. If the drill takes longer than 2.5 minutes, the reasons will be noted on the form and then another drill will be conducted within the same month until is it accomplished within the specified time. If the individual is still unable to evacuate within 2.5 minutes, a fire safety expert will be hired to determine if an extended evacuation time should be permitted for the individual in question. |
03/24/2023
| Implemented |
| 6400.251(b) | Individual #1 was admitted on 1/13/23 as an emergency placement and does not have a physical examination. | If an emergency placement occurs, § 6400.141 (relating to individual physical examination) shall be met within 31 calendar days after placement.
| DSP staff took individual #1 for a full physical examination with primary care physician. |
03/24/2023
| Implemented |
| 6400.166(a)(8) | Individual #1's March 2023 medication administration record documented Tylenol, 500mg, and Milk of Magnesia, and did not include a route of administration for the medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | Med Admin will update the MAR to include the route for each medication. |
05/01/2023
| Implemented |
| 6400.166(a)(9) | Individual #1's March 2023 medication administration record did not include the frequency of administraion for Milk of Magnesia. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | Med Admin will update the MAR to include the frequency for each medication. |
05/01/2023
| Implemented |
| 6400.166(a)(11) | Individual #1's March 2023 medication administration record did not include the diagnosis or purpose for Tylenol, 500mg, and Milk of Magnesia. | 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. | Program Specialist updated MAR to include the diagnosis or purpose for each medication. |
03/29/2023
| Implemented |
| 6400.167(a)(1) | Propranolol, 10mg, take 1 tablet by mouth twice daily for blood pressure prescribed to Individual #1 was not administered at 8:00AM on 3/10/2023 and at 8:00PM on 3/12/2023. | Medication errors include the following: Failure to administer a medication. | 03/31/23 Med Admin Trainer retrained implicated staff on the difference between a medication error due to failure of administration (167a1) and failure to immediately document the administration of a medication (166b). Implicated staff that administer medication were also trained on the requirement that an administration of a medication must be immediately recorded on the MAR following the administration of the medication.
3/31/23 Program Specialist filed a medication error incident for the 8:00AM and 8:00PM doses of Propranolol 10 mg on 3/10/2023 and 3/12/2023. Staff reported medication was administered, but not signed off on the MAR. A documentation error was recorded on the incident report. |
03/31/2023
| Implemented |
| 6400.207(4)(III) | Individual #1 is prescribed Lorazepam 1mg tablet, take 1 tablet by mouth as needed for anxiety one hour prior to appointment, and may repeat dose in 45 minutes if not calm. The medication was administered 3/10/2022 and 3/22/2022, and there are no written instructions by a physician or medical practitioner listing the individual's specific symptoms of the psychiatric diagnosis that would warrant the use of the medication, and the CEO or CEO designee did not authorize the administration of the medication. Individual #1 is prescribed Olanzapine 2.5mg tablet, take 2 tablets by mouth every 4 hours as needed for agitation. On 3/03/2022, 3/05/2022, 3/06/2022, 3/10/2022, 3/18/2022 and 3/22/2022, and there are no written instructions by a physician or medical practitioner listing the individual's specific symptoms of the psychiatric diagnosis that would warrant the use of the medication, and the CEO or CEO designee did not authorize the administration of the medication. | A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: An ongoing program of medication. | Program Specialist contacted the prescriber and requested an updated set of prescriptions be sent to the pharmacy that have a written criteria for passing a PRN medication that provides specific criteria related to the psychiatric diagnosis that warrants the use of the medication. Program Specialist will ensure that the written criteria is received from the practitioner and attached to each MAR by 5/1/2023.
3/30/23 Med Admin Trainer trained implicated staff that administer medication on LHC policy re: PRN Medication Administration. |
05/01/2023
| Implemented |