| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Financials were missing for Individual #1 for March 2021 at time of inspection. | 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 March 2021 expense report for individual #1 was found as it was mistakenly placed in the wrong binder but it was completed. The expense report itemizes all the expenses for March as well as deposits. The issue was we did not have a systematic approach to organizing consumer records so we developed a standardized way of organizing consumer records across our homes to prevent records from being misplaced. |
04/30/2021
| Implemented |
| 6400.22(e)(3) | No receipts provided for transactions over $15 for all individuals reviewed (Individual #1) | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | We make copies of all receipts of monthly consumer expenditures and attach them to their corresponding monthly expense reports. Before we used to save receipts in a secured area in the home and compile them when creating expense reports at the end of the month-- we noticed that this approach does not eliminate the chance that the receipt could be easily misplaced. Making copies of receipts and immediately attaching them to their corresponding expense report has eliminated this problem. |
04/30/2021
| Implemented |
| 6400.62(a) | Poisonous materials were not kept locked or made inaccessible to individual #1 there was Drain Maintenance cleaner in an unlocked bathroom drawer under the sink. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Each home was searched and all poisonous materials were kept in locked areas. |
04/30/2021
| Implemented |
| 6400.77(b) | The first aid kit did not contain a scissors at time of inspection. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | A new first aid kit was purchased which contains scissors, bandages, etc. First aid kits are checked routinely to ensure that all the necessary items are included. |
04/30/2021
| Implemented |
| 6400.101 | The exit route outside the backdoor gate was obstructed, the gate could not be utilized at time of inspection. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| The gate is secured as individual #1 is an elopement risk when experiencing symptoms of his psychosis which are unpredictable- behaviors have been noted on the ISP and BSP. The staff have been given the combination for the lock in the event of any emergency situations. |
04/30/2021
| Implemented |
| 6400.112(c) | Fire Drills were not compliant. From October 2020 thru March 2021,evacuation start and end time not clearly identified. | 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 fire drill forms were revised as requested to document start and end time as they were not clearly stated in the previous form. |
04/30/2021
| Implemented |
| 6400.113(a) | No proof of fire safety training was provide during this inspection for Individual #1 | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | The signed Fire Drill policy statement and Annual Fire Safety Training Record for individual #1 was submitted along with other requested documentation. |
04/30/2021
| Implemented |
| 6400.141(c)(1) | No medical history provided on Individual #1 Physical Examination Form dated 2/07/2021, this portion was omitted. (or left blank) | The physical examination shall include: A review of previous medical history. | Ensure that the clinician documents each individuals' medical history on subsequent Physical Examination forms; however, this examination form pre-dates the individual's care from Embolden- individual began receiving care from Embolden on April 1 2020 |
04/30/2021
| Implemented |
| 6400.141(c)(6) | The physical examination form dated 1/07/2020 for Individual #1 did not include a Tuberculin test by any method with negative results. This portion of the exam was left blank. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | This examination form pre-dates the individual's care from Embolden. The individual began receiving services from Embolden April 1, 2020. |
04/30/2021
| Implemented |
| 6400.31(a) | At time of inspection there was no signed copy of rights for Individual #1 | An individual may not be deprived of rights as provided under § 6400.32 (relating to rights of the individual.) | The signed copy of rights for individual #1 was provided. |
04/30/2021
| Implemented |
| 6400.46(a) | It could not be determined if direct service worker Staff #2 was trained before working with individuals in general fire safety, no verification of completed training provided at time of inspection. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | The General Fire Safety training certificate was provided for direct service worker #2. Each home has a custom Fire & Disaster Plan which also specifies evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedure, etc. |
04/30/2021
| Implemented |
| 6400.46(b) | It could not be determined if Program specialists Staff #1 was trained annually by a fire safety expert. No verification of completed training was provided at time of inspection. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | We have found local businesses that specialize in fire prevention to conduct additional fire safety training for staff. |
04/30/2021
| Implemented |
| 6400.163(h) | Prescription medications Quetiapine Fumarate 300mg was discontinued on 4/7/2021, the medication was located in the individual's #1 active medication box. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The Quetiapine Fumarate (AKA Seroquel) was increased from 200MG to 300MG on April 6 2021- only the 300MG medication was in the medication box (the discontinued 200MG had been disposed) as specified on the email sent April 18 2021. Thus the 300mg dose of the Seroquel (or Quetiapine Fumarate) was not discontinued and there was no compliance issue. |
04/30/2021
| Implemented |
| 6400.165(e) | Medication review for Individual #1 shows it cannot be determined if medication is being administered as prescribed. Medication OMEPRAZOLE DR is listed on the individuals MAR as 200MG, the prescription label on the medication bottle shows 20MG. | 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 MAR was revised to Omeprazole to document 20MG instead of 200MG. The instructions however were correct and after calculating the date the medication was filled, frequency and the quantity that was dispensed we found there was no errors in terms of administration. Nonetheless, we constantly make sure there no such errors on MARs. |
04/30/2021
| Implemented |
| 6400.169(a) | Qualification to administer medication for Program Specialist Staff #1 was not completed annually, last 12/09/2019. | 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). | The Program Specialist has completed the medications administration course - the Annual Practicum certification form was not submitted with the Initial training certification form by mistake. |
04/30/2021
| Implemented |