| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency did not provided documentation that they completed a self-assessment of the home(s) | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| The agency failed to complete a self-assessment for the home as no consumer was residing in the home 3 to 6 months prior to the expiration of the certificate of compliance.
On 6/25/24 the Executive Director and house supervisor completed a self-assessment for the home. |
06/25/2024
| Implemented |
| 6400.106 | The furnace did not have inspections completed. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| The agency failed to schedule an annual furnace inspection.
On 4/15/24, the Executive Director scheduled a furnace cleaning for the home. |
06/28/2024
| Implemented |
| 6400.113(a) | Documentation that the individual 1 was instructed upon initial admission 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 was not completed and not in individual's file. | 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 agency failed to obtain a copy of individual #1 fire safety training that was conducted on day one of admission into the program.
On 4/15/24, the Executive Director contacted the fire safety instructor to get a copy of the training signature sheet of individual #1 participation in fire safety training. |
06/28/2024
| Implemented |
| 6400.141(a) | Individual 1, current physical dated 3/12/24 did not include checks for vision, hearing, communicable disease precautions, assess of health maintenance, information pertinent to diagnosis in case of emergency. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The agency failed to properly exam individual #1s physical examination form prior to admission into the residential program.
On 6/25/24 the house supervisor scheduled individual #1 a new physical exam |
06/28/2024
| Implemented |
| 6400.141(c)(6) | Individual 1, physical dated 3/12//24 did not include a TB test. | 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. | The agency failed to ensure individual #1 had a TB test prior to admission into the residential program.
On 6/25/24 the house supervisor scheduled individual #1 a TB test. |
06/28/2024
| Implemented |
| 6400.144 | Individual #1 is logging the MAR as if she is self-medicating, the assessment states that individual is not self-medicating. Dates are OXCARBANZEPINE 300mg- 4/8,9,10,11,and 15. FAMOTICLINE 40mg -- (a.m dose) on 4/8,9,10,11,and 15. CHLORPROMAZINE 50mg- 5pm and 11pm she is administering this med 4/1 -- 4/15. | 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.
| The agency was logging the individual's initials instead of the administering staff's initials on the MAR.
On 4/15/24, the house supervisor discontinued having individual #1 sign on the MAR for their medications. |
06/28/2024
| Implemented |
| 6400.217 | Consents to release information were not completed for Wheelhouse, but for a day program that the individual is currently enrolled in. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| The agency failed to obtain consents for the release of information from individual #1 on the day of admission.
On 4/15/24, the house supervisor obtain individual's #1 consent for the release of information. |
06/28/2024
| Implemented |
| 6400.18(a)(5) | The agency did not report the incident that occurred on 04/09/2024 through the Department's information management system within 24 hours of discovery. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 24 hours of discovery by a staff person:
Neglect.
| The agency point person was unable to access individual #1 in EIM 24 hours of discovery of the incident.
On 4/11/24, individuals was entered into EIM once the point person was able to gain access to the online electronic application.
On 6/28/24, the agency point persons were retrained on the agency incident management policy and reporting forms by the Incident/Risk Manager. |
06/28/2024
| Implemented |
| 6400.34(b) | Individual 1, record did not contain a signed copy of rights. | The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights. | The agency failed to maintain a copy of individual's rights attestation form in her file in the home.
On 4/15/24, the house supervisor placed a copy of individual right attestation form in the individual #1 record at the home. |
06/25/2024
| Implemented |
| 6400.169(a) | The staff #4 and Staff #5 person(s) who administers medication to the individual for the 5pm and 11pm dosage did not provide documentation that they have successfully completed a department-approved medication administration course. (If not provided by 5pm the staff is no longer eligible to administer medication). Agency is to provide verification that the staff mentioned of completed medication course. | 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 staff's student medication administration training was at the agency's main office at the time of inspection.
On 4/15/24, the Executive Director completed an audit of the staff's training files. The Executive Director forwarded a copy of the staff #4 and staff #5 initial student course packets to the department. |
06/28/2024
| Implemented |
| 6400.213(1)(i) | Some of the information needed for identification purposes such as identifying marks, hair color and eye color were not in the record. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | The agency's demographi form did not contain spaces to document the individuals identifying marks, hair color and eye color.
On 6/25/24 the house supervisor updated individual #1 record to include information on the individual's identifying marks, hair color and eye color. |
06/25/2024
| Implemented |