| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(1) | Individual #1's physical examination, completed on 10/16/2023, did not include a review of the individual's previous medical history. A section to detail the individual's previous medical history was omitted from the physical examination form template. | The physical examination shall include: A review of previous medical history. | INDIVIDUAL#1 PHYSICAL WAS UPDATED BY CEO ON 6/6/2024 WHICH INCLUDE THE PREVIOUS MEDICAL HISTORY CHECKLIST.THIS FORM HAS BEEN ADDED TO HIS MEDICAL BINDER. |
06/06/2024
| Implemented |
| 6400.141(c)(11) | Individual #1's physical examination, completed on 10/16/2023, did not include an assessment of the individual's health maintenance needs. A section to detail the individual's health maintenance needs was omitted from the physical examination form template. | 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. | INDIVIDUAL#1 PHYSICAL WAS UPDATED BY CEO ON 6/6/2024 WHICH INCLUDE THE INDIVIDUALS HEALTH MAINTAINANCE NEEDS. THIS FORM HAS BEEN ADDED TO HIS MEDICAL BINDER. |
06/06/2024
| Implemented |
| 6400.34(a) | Individual #1 was informed of their rights and the process to report a rights violation on 10/16/2023. The review of rights on 10/16/2023 did not include the individual's right to speak freely as referenced in § 6400.32(b) nor did the review include that the individual's rights may only be modified in accordance with § 6400.185 to the extent necessary to mitigate a significant health and safety risk to the individual or others as referenced in § 6400.32(v). | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | INDIVIDUAL# 1 CLIENTS RIGHT WAS UPDATED ON 6/7/2024 WHICH REFLECTS THE 6400.32B,6400.185 AND 6400.32V. INDIVIDUAL#1 SIGNED THE UPDATED CLIENTS RIGHT AND IT HAS BEEN ADDED TO HIS PROGRAM CHART. |
06/07/2024
| Implemented |
| 6400.163(h) | On 6/05/2024 Individual #1's prescription Clindamycin Prop 1% Lotion "Apply topically twice a day to acne as needed for flares" was identified to having expired in May 2024. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | INDIVIDUAL#1 PRN CLINDAMYCIN PROP1% LOTION WAS REMOVED FROM THE MEDICATION LOCKED BOX IMMEDIATELY. ANOTHER ONE WAS ORDERED AND IT WAS DELIVERED THE SECOND DAY. |
06/10/2024
| Implemented |
| 6400.166(a)(11) | On 6/05/2024 Individual #1's June 2024 medication administration record did not include diagnosis or purpose for prescribed Icy Hot Cream. | 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. | INDIVIDUAL#1 MAR WAS UPDATED ON 6/7/2024. THE CEO REACHED OUT TO THE PHYSICIAN OFFICE WHO PRESCRIBED THE ICY HOT CREAM AND WE WERE GIVEN THE PURPOSE OF THE CREAM.
WE SENT IT TO THE PHARMACY AND IT WAS UPDATED ON HIS MAR. IT HAS BEEN ADDED TO HIS MAR BINDER. |
06/07/2024
| Implemented |
| 6400.182(c) | Individual #1's individual support plan, last updated 5/17/2024, states he needs assistance managing his spending money and personal finances Chief Executive Officer #1 states the individual is independent in his spending money provided to him by his representative payee. Individual #1's behavior support plan, last updated 2/10/2024, and the individual support plan, last updated 5/17/2024, states all sharps should be locked up when not in use. Chief Executive Officer #1 stated the individual has been assessed safe with sharps and they are not being locked in the home. Individual #1's behavior support plan, last updated 2/10/2024, states the individual's diet has restrictions on caffeine and red dye, the individual can have 24 ounces of sugar and caffeine-free pop per day, the total fluid ounces per day must be 131 ounces, the individual from 10:00pm to 7:00am can have no food or drink besides water, and that he is limited to 1 ox of macaroni and cheese per day. There is no doctor's order for this diet restriction and the diet is not being followed in the home. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | THE CEO REACHED OUT TO THE SUPPORT COORDINATOR TO UPDATE INDIVIDUAL#1 ISP TO REFLECT HE CAN MANAGE HIS MONEY AND TO REMOVE THE FLUID RESTRCTIONS IN HIS ISP.
THE CEO REACHED OUT TO INDIVIDUAL#1 BEHAVIOR SPECIALIST TO UPDATE HIS BEHAVIOR SUPPORT PLAN TO REFLECT THAT SHARP OBJECT DOESNT NEED TO BE LOCKED. |
06/11/2024
| Implemented |
| 6400.213(1)(i) | Individual #1's demographic form did not include identifying marks. This section had been omitted from the demographic form template. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | INDIVIDUAL#1 DEMOGRAPHIC FORM HAS BEEN UPDATED TO INCLUDE IDENTYING MARK, THIS FORM HAS BEEN ADDED TO HIS PROGRAM CHART. |
06/07/2024
| Implemented |