| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(c) | The fire drill records for the 5/10/22 and 12/29/22 fire drills do not include the amount of time it took for evacuation. | 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 February 8, 2023, the director spoke to the Lead worker, and had them check the house notes for the times of each fire drill that was missing. They were able to give the director the amount of time it took for the two fire drills of 5/10/22 and 12/29/22 to be completed. The time was written in on the two fire drills. |
03/08/2023
| Implemented |
| 6400.141(c)(13) | Individual #1's 11/21/22 annual physical examination does not list that Individual #1 has seasonal allergies. | The physical examination shall include: Allergies or contraindicated medications. | The director has sent the physical form to the PCP office for Individual #1, to have seasonal allergies added to the physical. The updated physical will be completed by 3/31/23. |
03/13/2023
| Implemented |
| 6400.141(c)(14) | The medical information pertinent to diagnosis or treatment in case of emergency section of Individual #1's 11/21/22 annual physical examination only states, "Call 911." | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The director has sent the physical form to the PCP office for Individual #1, to have pertinent medical information in case of an emergency added to the physical. The updated physical will be completed by 3/31/23. |
03/13/2023
| Implemented |
| 6400.151(c)(2) | Staff person #3 had a tuberculin test completed on 12/16/20 and not again until 1/29/23. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | Staff that have not complied with the letter for their physical and TB by a specific date, will be suspended and not allowed to work with individuals until they have been completed and reviewed by the director. |
03/15/2023
| Implemented |
| 6400.151(c)(3) | Staff person #4's 7/19/22 physical examination indicates that they are not free of communicable diseases and there are no special precautions included in the examination. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | Staff #4 has been given their physical to have their doctor address the "not free of communicable diseases" and has been directed to have it addressed or redone at this time for they are free of communicable disease or the precautions that are needed to prevent spread of disease. This will be completed by 3/27/23. |
03/15/2023
| Implemented |
| 6400.181(e)(1) | Individual #1's 11/8/22 assessment does not include the individual's functional strengths, needs, and preferences. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | March 13, 2023, the director has corrected Individual #1's assessment along with the other individuals' assessments, to have their functional strengths, needs, and preferences written in each plan and in their own section. |
03/13/2023
| Implemented |
| 6400.181(e)(13)(iii) | Individual #1's 11/8/22 assessment does not include the individual's current level and progress in the area of activities of residential living. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Activities of residential living. | March 13, 2023, the director has corrected Individual #1's assessment along with the other individuals' assessments, to have their current level and progress in the area of activities of residential living written in each plan and in their own section. |
03/13/2023
| Implemented |
| 6400.18(b)(2) | Individual #1 did not receive their medication Latuda on 10/11/22. This was discovered on 10/12/22 but not reported in the Department's Incident Management system until 10/17/22. | 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 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | The director took Leaderships Role in Reporting, Investigating, and Responding to Incidents training on MYODP on 3/14/2023. |
03/14/2023
| Implemented |
| 6400.165(g) | Individual #1 had multiple medication reviews between 9/30/22 and 3/7/23 (10/17/22, 10/24/22, 11/7/22, 12/19/22, 1/9/23, 1/30/23, 2/13/23). None of these reviews included the reason for prescribing the medication or the necessary dosage amounts. | 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 director requested notes from DDTT for the medication reviews that took place between 9/30/22 thru 3/7/23. |
03/08/2023
| Implemented |
| 6400.166(a)(10) | Individual #1 was administered PRN Trazodone and PRN Hydroxyzine on 10/24/22. There are no administration times listed for these occurrences. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | The staff person that administered the medication and did not write on the back of the MAR when the medication was given or the reason why and times, has had their medication administration privileges suspended and will have to retake the class by the end of April 2023. |
03/10/2023
| Implemented |
| 6400.166(a)(11) | Individual #1's September and October Medication Administration Records do not include the diagnosis or purpose for Clindamycin HCL 300mg. | 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. | All medication trained staff will be trained on "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 PRN medications" by the end of March 2023. |
03/16/2023
| Implemented |
| 6400.166(b) | On 3/6/23, Individual #1 refused to take any of their 8pm medications. This was not documented on the MAR. The Medication Administration for 3/6/23 at 8pm was blank. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The director looked in the daily notes and verified that the medications were not given and were refused. The staff person that attempted to administer the medication and did not write on the back of the MAR the medication refusal, has had their medication privileges suspended and will have to retake the class by the end of April 2023. |
03/10/2023
| Implemented |
| 6400.167(a)(1) | Individual #1 was not administered their 8pm Clindamycin wipes on 11/5/22 through 11/13/22, 2/2/23-2/3/23, and 2/26/23. Individual #1 was not administered their 8am Clindamycin wipes on 11/5/22-11/6/22 or from 11/12/22-11/14/22. Individual #1 was not administered their 8pm Latuda on 10/12/22-10/17/22. | Medication errors include the following: Failure to administer a medication. | All medication trained staff will be trained on compliance of administering medications, if the medication is running low to call the pharmacy and ask for it to be refilled. All med trained staff will be prompted to call the prescribing doctor of the medication if we were unable to get a medication in due to supply shortages, and/or a prior authorization is needed for a medication. This training will be reviewed by the med trainer to all staff by the end of March 2023. |
03/16/2023
| Implemented |
| 6400.167(c) | The medication errors described in 6400.167(a)(1) were not reported in the department's incident management system. | A medication error shall be reported as an incident as specified in § 6400.18(b) (relating to incident report and investigation). | The director took Leaderships Role in Reporting, Investigating, and Responding to Incidents training on MYODP on 3/14/2023. |
03/14/2023
| Implemented |
| 6400.213(1)(i) | At the time of the inspection, Individual #1's religion was listed as "unknown" on the face sheet indicating they were not asked about their religious preference. | Each individual's record must include the following information: Religion. | The director spoke with individual #1 and asked them what they wanted their religion to be documented as; individual #1 reported to the director on 3/6/23 that they had no religion. The face sheet was changed to the individual's preference on 3/6/23. |
03/15/2023
| Implemented |