Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.22(d)(1) | On 08/18/24, Individual #1 purchased a rocking chair for $186.55; this item was not on Individual #1 property record. | 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. | This occurred due to a lack of a formalized process in place to update client inventory (personal property inventory). Program Manager completed an updated client inventory (personal property inventory) on 3/26/2025 indicating the purchase of a rocking chair on 8/18/24 (see attached "22d1 Client Inventory"). |
04/30/2025
| Implemented |
6400.144 | Individual #1's annual physical from 10/12/23 ordered that cholesterol and blood sugar levels are to be tested annually. No documentation was provided verifying that this occurred. The annual physical completed on 10/15/24 recommended lab work be completed every six months. Lab work is not being completed every six months. Additionally, it was recommended that Individual #1 have labs drawn a few weeks prior to their 03/14/25 Primary Care Provider appointment. This did not occur. Individual #1 had a podiatry appointment on 04/29/24. There was to be follow-up in three to four months. The follow-up appointment did not take place until December 2024. (Repeat from 04/03/24 Inspection) | 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.
| This occurred due to a lack of process being in place to alert management when individuals are due for recommended lab work that should take place on a regular basis. Individual #1 had lab work completed on 04/02/2025 (see attached "144 Lab work from 04 02 2025"). Director of Service Impact and Director of Nursing are meeting with Program Specialists on 4/16/2025 to train on the roll out a new module in the EHR (Therap) to automate health recommendations including lab work, physicals, specialist appointments, etc. This module allows for Program Specialists to record at what frequency health screenings should occur and schedule alerts as they approach their due date to avoid missed follow ups. This new module will be active in Therap by 5/30/2025. |
04/30/2025
| Implemented |
6400.181(e)(13)(i) | Individual #1's most recent Annual Assessment completed on 08/09/24 does not adequately and thoroughly document the individual's health and how their health status progressed through the year. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| This occurred due to lack of training on the necessity to provide detailed progress when completing annual assessments. An addendum to the 8/9/24 annual assessment was completed on 4/11/2025 and shared with the individual's team. See attached "181 Addendum 04 11 2025". |
04/30/2025
| Implemented |
6400.181(e)(13)(vi) | Individual #1's most recent Annual Assessment completed on 08/09/24 does not adequately and thoroughly document the individual's recreation preferences and how they progressed through the year in this category. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Recreation. | This occurred due to lack of training on the necessity to provide detailed progress when completing annual assessments. An addendum to the 8/9/24 annual assessment was completed on 4/11/2025 and shared with the individual's team. See attached "181 Addendum 04 11 2025". |
04/30/2025
| Implemented |
6400.211(b)(2) | Individual #1's demographic information does not include the name, address, or phone number of their physician. | Emergency information for each individual shall include the following: The name, address and telephone number of the individual's physician or source of health care. | This occurred due to an error in inputting physician's name, address, and phone number for the physician. Immediately upon discovery, this was resolved. See "Active Contacts section of attached 211b2 Demographic Information." |
04/30/2025
| Implemented |
6400.32(c) | Individual #1 has a bowel movement protocol that their bowel movements are to be tracked daily. If they go 48 hours with no bowel movement, they are to receive an additional dose of Senna. They are to receive the medication daily until they have a bowel movement. If Individual #1 goes four days with no bowel movement, their Primary Care Provider (PCP) is to be called. From April 2024 through March 2025, Individual #1 went without a bowel movement for 48 hours a total of 12 times. Individual #1 went without a bowel movement a total of three days five times. They went without a bowel movement four or more days a total of 7 times. The longest stretch without a bowel movement was five days. No PRN Senna was given, and the individual's PCP was not contacted as per the protocol. During the review period, there were 16 days without documentation regarding if the individual had a bowel movement. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | This occurred due to failure of direct care staff to document bowel movements and of management to monitor tracking to ensure protocols were being followed as prescribed. A bowel protocol audit to ensure present protocols align with doctor recommendations and prescribed medications was completed by Program Specialists on 3/28/2025. |
05/30/2025
| Implemented |
6400.165(c) | The requirements of this will be trained on during TLC's Plan of Correction Training with TLC Leadership, Program Specialists, Program Managers, and Incident Management Coordinators on April 30, 2025. | A prescription medication shall be administered as prescribed. | This occurred due to lack of training on adding end dates to Carasolva (eMAR) for short-term medications. The medication was started on a paper MAR prior to being added to the eMAR; subsequently the proper end date was not added so staff created a documentation error by signing off on 6/22's 8AM administration time. EIM #9600875 was input to account for the error. |
05/30/2025
| Implemented |
6400.166(b) | Individual #1 had medication administrations that were not logged immediately on 06/24/24, 7/26/24, 11/01/24, 11/16/24, 01/04/24, 01/11/24, 01/26/24, 02/07/24, 02/13/24, 02/19/24, 02/22/24, 02/23/24, 03/06/24, and 03/19/24. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | This occurred due to lack of training on the necessity of completing paper MARs in the event of Carasolva downtime and/or being in the community during medication administration. DSPs will be retrained on the importance of completing paper MARs for late administration in addition to later documenting the late administration in Carasolva by Program Managers during house meetings in the month of May during the DSP Plan of Correction Training. |
05/30/2025
| Implemented |
6400.167(a)(1) | Individual #1 did not receive their 8:00pm doses of Docusate Sodium, Perphenazine, or Risperidone on 10/28/24. They did not receive any of their 8:00am medications on 12/28/24. | Medication errors include the following: Failure to administer a medication. | This occurred due to DSP staff failing to adhere to Medication Administration guidelines and administer medication in the required timeframe. In addition, the Program Manager failed to catch this error when completing their Weekly Medication Audit. EIM #s: 9594130 and 9594156 were input to account for omissions of medication. |
05/30/2025
| Implemented |
6400.183(a)(2) | Individual #1's mother did not attend the January 2025 Individual Support Plan team meeting. | The individual plan shall be developed by an interdisciplinary team, including the following: Persons designated by the individual. | This occurred due to Individual #1's mother choosing not to participate in the annual ISP meeting and the team failing to document. In the future, if an individual's designated person chooses not to participate, the Program Specialist will document on ISP signature sheet provided from the SC that the designated person chose not to attend. |
04/30/2025
| Implemented |