| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | The home shall keep an up-to-date financial and property record for each individual. The beginning balance for the February 2024 financial record was recorded as $32.70. There was no ending balance recorded for February 2024. There was no financial record for March 2024. There was no begin or ending balance for April 2024, although transactions were recorded. The record noted a beginning balance of $90.00 and ending balance of $18.26 for May 2024. A beginning balance of $18.26 and end balance of $0.14 for June 2024. Due to lack of documentation, the correct balance that remained for Individual #1 could not be determined, and funds received by or deposited with the home for the period of February 2024 through the end of June 2024 were not recorded in the financial record. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | The individual funds were reconciled. The former program specialist did not update the March financial records, resulting in incorrect numbers entering for the months that followed. The opening balance for February was $32.70 and the ending balance for March was $23.63. The opening balance for March was $23.63 and the ending balance was $70.13. The opening balance for April was $70.13 and the ending balance was $4.04. The opening balance for May was $4.04 and the ending balance was $25.16. The month of June opened with $25.16 and ended with $6.91. For July, the opening balance was $6.91 and the ending balance was $8.26. |
08/30/2024
| Implemented |
| 6400.22(d)(2) | The home shall keep an up-to-date financial and property record for each individual. The beginning balance for the February 2024 financial record was recorded as $32.70. There was no ending balance recorded for February 2024. There was no financial record for March 2024. There was no begin or ending balance for April 2024, although transactions were recorded. The record noted a beginning balance of $90.00 and ending balance of $18.26 for May 2024. A beginning balance of $18.26 and end balance of $0.14 for June 2024. Due to lack of documentation, the correct balance that remained for Individual #1 could not be determined, and disbursements made to or for the individual for the period of February 2024 through the end of June 2024 were not recorded in the financial record. | The home shall keep an up-to-date financial and property record for each individual, including (2) Disbursements made to or for the individual. | The individual funds were reconciled. The former program specialist did not update the March financial records, resulting in incorrect numbers entering for the months that followed. The opening balance for February was $32.70 and the ending balance for March was $23.63. The opening balance for March was $23.63 and the ending balance was $70.13. The opening balance for April was $70.13 and the ending balance was $4.04. The opening balance for May was $4.04 and the ending balance was $25.16. The month of June opened with $25.16 and ended with $6.91. $6.91 opening balance for July and ending balance of $8.26. |
08/01/2024
| Implemented |
| 6400.67(b) | An electrical outlet cover was held onto the outlet and wall by tape in the licensed basement area of the home used as the agency's office. The improperly fastened outlet cover created a potential electrical hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The improperly fastened electrical outlet cover in the basement area has been corrected, with the outlet cover securely reattached according to safety standards. |
07/08/2024
| Implemented |
| 6400.80(a) | At time of inspection a large indoor carpet, approximately 10x12 was hanging over the deck rail and landing upon the stairs leading from the deck to the back yard. The carpet covered approximately five stairs creating an obstruction and tripping hazard. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | The tripping hazard caused by the large indoor carpet hanging over the deck rail and obstructing the stairs has been corrected, with the carpet promptly removed and stored appropriately |
07/01/2024
| Implemented |
| 6400.112(c) | Documentation of the fire drill completed on 5/1/24 did not include the time that the fire drill was completed. The time the fire drill was completed is a required component of the written fire drill record. | 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. | The documentation for the fire drill completed on 5/1/24 has been updated to include the missing time, ensuring that all required components are now recorded |
08/01/2024
| Implemented |
| 6400.142(f) | There was no dental hygiene plan in place for Individual #1 at time of inspection. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | The issue of Individual #1 lacking a dental hygiene plan in their record has been corrected, with a comprehensive dental hygiene plan now documented and included in their file by the clinical director |
08/11/2024
| Implemented |
| 6400.151(a) | The hire date provided for Staff #3 was 4/8/24. The physical submitted for Staff #3 was completed on 6/3/24. This is outside of the required timeframes. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | A new protocol has been established to ensure that all staff undergo physical examinations within the required timeframe prior to or shortly after their hire date |
07/24/2024
| Implemented |
| 6400.62(b) | Individual #1 Individual Support Plan (ISP) states
"There is no need to keep poisonous substances locked away." Individual #2 ISP states "cleaning products and poisonous substances are kept in certain areas of the home away from [Individual #2] reach." During inspection of the home it was noted that poisons and cleaning supplies were kept under the kitchen sink of the home. The door was equipped with a lock but the lock was not engaged at the time of inspection and poisonous substances and cleaning supplies were within reach of Individual #2. Poisonous materials may be kept unlocked if all individuals living in the home are able to safely use or avoid poisonous materials. | Poisonous materials may be kept unlocked if all individuals living in the home are able to safely use or avoid poisonous materials. Documentation of each individual's ability to safely use or avoid poisonous materials shall be in each individual's assessment. | The lock on the cabinet has been engaged, ensuring that these materials are now secured and out of reach of Individual #1, in accordance with their Individual Support Plan (ISP) |
07/01/2024
| Implemented |
| 6400.32(h) | An individual has the right to privacy of person and possessions. Individuals #1 and #2 reside at the home which is also the location of the Agency's main office. The Provider's office is located in the basement of the home, and visitors enter the home through the front door and walk through the living room to access the stairs to the basement office. The individuals' right to privacy is violated by the flow of traffic in and out of the home by persons who are there to conduct business with the Provider as opposed to the home or its residents. There were sliding glass doors from the basement office to a fenced backyard, but the yard was somewhat overgrown, and it did not appear that the sliding doors were not being used to access the office. | An individual has the right to privacy of person and possessions. | The agency office has been moved to separate office location allowing for the individuals residing at the home to have their privacy |
07/08/2024
| Implemented |
| 6400.46(c) | Staff #1 had a hire date submitted as 12/23/23, documentation of training on first aid techniques is documented as occurring on 3/8/24 which is outside of the required timeframes. | Program specialists and direct service workers and at least one person in a vehicle while individuals are being transported by the home shall be trained before working with individuals in first aid techniques. | A new protocol has been implemented to ensure that all required training is completed within the designated timeframe before staff begin their duties. |
07/24/2024
| Implemented |
| 6400.51(b)(3) | Staff #1 has a documented hire date of 12/23/23. Documentation of training on Individual Rights was dated as occurring on 2/23/24. Staff #1 did not receive the required training within 30 days after hire. | The orientation must encompass the following areas: Individual rights. | A new protocol ensures that all required training, including Individual Rights, is completed within 30 days of hire. The HR department has improved its tracking system to monitor training deadlines and ensure timely completion. |
07/24/2024
| Implemented |
| 6400.165(c) | Individual #1 is prescribed Norethind-Eth Estrad a birth control pill. At time of inspection on Monday, 7/1/24, the two pills remaining in the pack were found in the Monday and Tuesday blisters of the fourth row of blisters in the package. When questioned management explained that a staff member mistakenly popped the pill at the right end of the row, so they were now administering the pills from right to left rather than left to right as prescribed and labeled in the package. Due to the specific and different dosage in each tablet the medication was not administered as prescribed. | A prescription medication shall be administered as prescribed. | All staff involved in making the mistake in medication administration have been retrained on the importance of following the prescribed administration schedule and accurately reading medication labels. |
07/05/2024
| Implemented |
| 6400.165(g) | Documentation of medication reviews completed on 3/13/24, 3/20/24, and 4/17/24 did not include the need to continue the medication as required. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | The documents were dropped off to the psychiatrist for completion and accuracy |
08/26/2024
| Implemented |
| 6400.166(a)(8) | The June 2024 Medication Administration Record (MAR) for Individual #1 contained an entry for Clobazam 10 mg tablet that was written as "Take 1 and ½ tablets every evening." The MAR entry for the medication did not contain the route of administration as required. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | The MAR was immediately updated to include route of administration |
08/01/2024
| Implemented |
| 6400.166(a)(11) | The June 2024 Medication Administration Record (MAR) for Individual #1 did not include documentation of the diagnosis or purpose of the mediation Clonidine as required. | 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 medication administration record (MAR) for Individual #1 will be updated immediately to include the diagnosis and purpose for he mediation Clonidine |
07/01/2024
| Implemented |
| 6400.169(a) | Staff #3 had documentation of medication administration training being complete of 3/2/22. There was no additional documentation to support that Staff #3 had completed the course renewal requirements needed to maintain the proper medication training required to be able to administer medications. The June 2024 Medication Administration Records for Individual #1 note that Staff #3 administered medications on June 14 and 27 of 2024 as indicated by their initials to signify that administration was complete. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Staff #3 was immediately refrained from administering medication up to August 28th when her training was completed including observation. |
08/26/2024
| Implemented |
| 6400.169(b)(2) | There was no documentation to support that Staff #3 completed the required department-approved diabetes patient education program within the past 12 months as required to administer insulin injections. The June 2024 Medication Administration Record (MAR) for Individual #1 noted the initials designated for Staff #3 for the Tresiba Flextouch on 6/3/24, 6/21/24 and 6/27/24 indicating that they administered the medication. The initials for Staff #3 also indicated that they completed administration of the Liraglutide Injection on 6/21/24 and 6/27/24. | A staff person may administer insulin injections following successful completion of both: A Department-approved diabetes patient education program within the past 12 months. | Staff #3 had an insulin training renewal completed on 6/23/2023 but the updated certificate was not on file. Certificate has been submitted, printed and added on file. In the interim, staff #3 was not allowed to administer any insulin |
08/01/2024
| Implemented |
| 6400.194(b) | The Human Rights Team meeting and approval document for the Restrictive Procedure Plan for Individual #1 dated 5/21/24 noted voting members to be Staff #4, Staff #5 and Staff #6. There was no additional identifying or credentialing information included on the signature sheet to indicate that one of the approving parties was a professional who has a recognized degree, certification or license relating to behavioral support, who did not develop the behavior support component of the individual plan. | The human rights team shall include a professional who has a recognized degree, certification or license relating to behavioral support, who did not develop the behavior support component of the individual plan. | The issue with the Human Rights Team meeting and approval document for the Restrictive Procedure Plan for Individual #1, dated 5/21/24, has been resolved. The document has been updated to include identifying and credentialing information for all voting members, ensuring that one of the approving parties is a professional with a recognized degree, certification, or license in behavioral support who did not develop the behavior support component of the individual plan. All members submitted their credentials for verification |
08/21/2024
| Implemented |
| 6400.194(c) | The Human Rights Team meeting and approval document for the Restrictive Procedure Plan for Individual #1 dated 5/21/24 noted voting members to be Staff #4, Staff #5 and Staff #6. There was no additional identifying or credentialing information included on the signature sheet to indicate that the approving human rights team included a majority of persons who do not provide direct services to the individual. | The human rights team shall include a majority of persons who do not provide direct services to the individual. | The issue with the Human Rights Team meeting and approval document for the Restrictive Procedure Plan for Individual #1, dated 5/21/24, has been resolved. The document has been updated to include the required identifying and credentialing information, ensuring that the majority of the approving human rights team members do not provide direct services to the individual. |
09/06/2024
| Implemented |