Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.141(c)(3) | Individual #3 did not have immunizations documented in her file or on her physical examination. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Individual #1's medical records were located. Her TDaP was on there from 2010. Due to the fact that it was expired, she received a new TDaP immunization on 03-16-2021. (See attached document in email to Kristen.) |
02/04/2021
| Implemented |
6400.181(e)(10) | Individual #3 did not have a lifetime medical history documented in her files. | The assessment must include the following information: A lifetime medical history. | The medical records and history were eventually obtained for Individual #1 and a lifetime medical history was developed from it and added into the assessment. |
02/04/2021
| Implemented |
6400.34(a) | Individual rights signed by Individual #3 and additional rights provided to licensing representatives as part of the annual inspection do not reflect changes to individual rights included in the updated 6100 regulations. | 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. | Updated individual's rights is now on file. The updated individual rights was explained to the individual and she signed it. Moving forward agency will check on 6100 Regulation regularly. See attached updated individual's rights emailed to Kristen. |
02/04/2021
| Implemented |
6400.165(c) | Individual # 3 is prescribed a PRN for Ibuprophen 200mg tab directed to take 3 tabs every 8 hours as needed for pain or headache was on the Medication Administration Record but was not in the home. Due to the medication not being in the home, it is unclear if the medication has been administered as prescribed. | A prescription medication shall be administered as prescribed. | Staff was retrained. Site Supervisor has obtained Ibuprohen script and Ibuprophen was delivered to the home. Moving Forward quality assurance will audit PRN medication weekly. See attached picture of ibuprohen medication that was delivered. |
01/13/2021
| Implemented |
6400.165(g) | Individual # 3 is prescribed medication to treat psychiatric illness, review of documentation indicates individual did not see a licensed physician to review the medications and treatments during the time period reviewed. | 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. | Staff was retrained. Moving forward it was implemented that every three months that Pshychiatry medication review is due, site supervisor will take the psychiatry review forms to the doctor's office for proper review. See attached Psych meds review form. |
01/19/2021
| Implemented |
6400.186 | Individual # 3's ISP reflects that the individuals needs assistance with budgeting and paying bills on time and they are in the process of discussing a rep payee with her. No financial records or documentation of assistance with budgeting or bill pay were provided at the time of inspection. | The home shall implement the individual plan, including revisions. | It was implemented that, Conference of churches will be the individual's Rep payee. Moving forward the agency has started a ledger to track and account for the individual's finances . A financial policy has been implemented for staff to read, sign, and follow it when caring for the individuals. staff has been retrained on how to assist the individual with budgeting. Quality assurance will conduct an audit twice a month. See attached copy of money ledger developed and staff training signed off emailed to Kristen. |
02/05/2021
| Implemented |