| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.110(e) | On 6/26/24 at 11:12AM, the smoke detector in the basement of the home was not interconnected with the smoke detector on the first floor of the home. | If the home serves four or more individuals or if the home has three or more stories including the basement and attic, there shall be at least one smoke detector on each floor interconnected and audible throughout the home or an automatic fire alarm system that is audible throughout the home. The requirement for homes with three or more stories does not apply to homes licensed in accordance with this chapter prior to November 8, 1991. | Freedom Community Connections CEO reset the smoke detectors during inspection in the presence of the licensing inspectors and was functionable on 6/26/24. A replacement of interconnecting smoking detectors was purchased and has now been installed at the site on 7/8/24. Smoking detectors are interconnected and is in working mode. |
06/26/2024
| Implemented |
| 6400.141(c)(1) | Individual #1's physical examination, completed 1/18/24 did not include a review of previous medical history. | The physical examination shall include: A review of previous medical history. | Freedom Community Connections annual physical form was updated on 7/2/2024 to include previous medical history. All old forms were shredded to ensure old forms are not being utilized during appointments. |
07/02/2024
| Not Implemented |
| 6400.141(c)(11) | Individual #1's physical examination, completed 1/18/24 did not include an assessment of the Individual's health maintenance needs. Individual #2's physical examination, completed 9/4/23 did not include an assessment of the individual's health maintenance needs. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | Freedom Community Connections annual physical form was updated on 7/2/2024 to include individual¿s health maintenance needs, and medication regimen. All old forms were shredded to ensure old forms are not being utilized during appointments. |
07/02/2024
| Not Implemented |
| 6400.144 | On 6/26/23 at 10:10AM, Individual #2 is prescribed an Epinephrine 0.3mg auto inject. Individual #2's Epinephrine auto inject pens remained at the home while Individual #2 was out of the home with staff. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Freedom Community Connections created a protocol on 6/26/24 for Epinephrine auto injector for outings in the community as well as work. All staff were trained and educated on the protocol to be followed; during [Individual #1] outings the EpiPen will accompany staff in the event it has to be used. |
06/26/2024
| Implemented |
| 6400.151(c)(1) | Direct Service Worker #1, hire date of 9/7/23, did not have physical examination until 9/8/23. Direct Service Worker #1 participate in a fire drill with Individual #2 on 9/5/23. | The physical examination shall include: A general physical examination. | Freedom Community Connections will ensure all staff will complete and submit a general physical examination prior to working a shift at the site when hired. FCC will not release any staff to work if a physical form is not completed within the timeframe requested. |
07/01/2024
| Implemented |
| 6400.181(e)(2) | Individual #2's assessment, completed 10/3/23 did not include dislikes of the individual. | The assessment must include the following information: The likes, dislikes and interest of the individual. | Freedom Community Connections revised the initial assessment to include the dislikes of the individual and submitted the plan to the team on 7/8/2024. |
07/10/2024
| Implemented |
| 6400.181(e)(14) | Individual #2's assessment, completed 10/3/23 did not include the ability to swim. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | Freedom Community Connections revised the initial assessment to include the ability to swim information of the individual and submitted the plan to the team on 7/8/2024. |
07/08/2024
| Implemented |
| 6400.50(a) | Direct Service Worker #1 has a 9/7/23 documented date of completing the required orientation training topics that are listed in 6400.51b1-4. The agency doesn't have any documentation of training source, content, or copies of certificate for these trainings. Chief Executive Officer #2 has a 7/1/23 documented date of completing the required orientation training topics that are listed in 6400.51b1-4. The agency doesn't have any documentation of training source, content, or copies of certificate for these trainings. Program Specialist #3 has a 10/30/23 documented date of completing the required orientation training topics that are listed in 6400.51b1, b2, and b4. The agency doesn't have any documentation of training source, content, or copies of certificate for these trainings. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | Freedom Community Connections new hires will complete orientation to include all training topics. Staff will not be released to work if training has not been met. Agency training will be completed on the myodp website and the NADSP E Badge Academy and will keep track of the training certificates for their records. |
07/01/2024
| Not Implemented |
| 6400.51(b)(3) | Program Specialist #3, date of hire 10/30/23, did not complete orientation training on individual rights until 1/30/24. | The orientation must encompass the following areas: Individual rights. | Freedom Community Connections new hires will complete orientation to include all training topics. Staff will not be released to work if training has not been met. Agency training will be completed on the myodp website and the NADSP E Badge Academy and will keep track of the training certificates for their records. All administration will be retrained. |
07/01/2024
| Not Implemented |
| 6400.166(a)(11) | Individual #1's June 2024 medication administration record did not include the purpose or diagnosis for Nicotine 14mg patch and Xarelto 20mg tablet. Individual #2's June 2024 medication administration record did not include the purpose or diagnosis for Clozapine 200mg, Clozapine 50mg, Flintstones complete chew, Magnesium Oxide 400mg, Melatonin 3mg tablet, Multivitamin tablet, Topiramate 50mg tablet, and Trazadone 50mg tablet, | 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. | Freedom Community Connections Medication Trainer added all medications that did not include the diagnosis or purpose of the medication on 6/26/2024 while inspectors were on site during inspection on the MAR and medication packet. FCC Medication Trainer also contacted the pharmacy to update all medication packet and MAR for the month of July to include all missing purpose and diagnosis. Medication trainer reviewed the MAR to ensure it is compliant. |
06/26/2024
| Implemented |
| 6400.166(a)(15) | Individual #2 is prescribed Epinephrine 0.3mg auto inject pen with instructions to inject 0.3 milliliter intramuscularly as a one time dose if needed for anaphylaxis if anaphylactic symptoms persist, dose may be repeated. The instructions for this medication on the June 2024 medication administration record, did not include "if anaphylactic symptoms persist dose may be repeated". | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Special precautions, if applicable. | Freedom Community Connections Medication Trainer added special instructions of the medication on 6/26/2024 while inspectors were on site during inspection on the MAR and medication packet. FCC Medication Trainer also contacted the pharmacy to update all medication packet and MAR for the month of July to include all special instructions. Medication trainer reviewed the MAR to ensure it is compliant. |
06/26/2024
| Implemented |
| 6400.169(a) | Program Specialist #3 has not completed the Department-approved medication administration training course. On 6/11/24 at 1:00PM, Program Specialist #3 administered Guanfacine 1mg to Individual #1. | 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). | Freedom Community Connections will develop and create a SEEP plan to address social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. |
08/09/2024
| Not Implemented |