| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(3) | Provider became the payee for individual 1 on 11/26/23, there was no ledger/receipts for transactions over $15.00. The money logbook shows transactions from $20.00 upwards to$100.00. from 10/27/23 -1/24/24. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | Direct support will get a receipt from all transactions for their consumer. All receipts collected will be kept in a pouch in the glove compartment of the homes vehicles. Supervisor will pick-up receipts weekly and log them into a ledger in the company office. |
02/05/2024
| Implemented |
| 6400.43(b)(1) | The CEO shall be responsible for the administration and general management of the home, including policies/procedures. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | CEO will update policies and procedures as they change in 6400 regulations. |
02/01/2024
| Implemented |
| 6400.71 | There were no emergency numbers listed by the telephone. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be on or by each telephone in the home with an outside line.
| A new sign with emergency numbers will be placed by the telephone at all times. Direct support will ensure that all forms are in their proper places. If a form becomes damaged or misplaced direct support will notify management immediately |
02/05/2024
| Implemented |
| 6400.72(a) | No screen in 2nd window in individual 1's bedroom.
No screen in individual 1's bathroom window. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | Our maintenance team will do a walk through immediately, and fix all items needed to be repaired. Direct support will fill out a maintenance log as damages/ repairs are done. |
02/15/2024
| Implemented |
| 6400.72(b) | The Closet door was off track in the vacant bedroom. | Screens, windows and doors shall be in good repair. | Our maintenance team will do a walk through immediately, and fix all items needed to be repaired. Direct support will fill out a maintenance log as damages/ repairs are done. |
02/15/2024
| Implemented |
| 6400.77(b) | The First Aid kit did not contain a thermometer. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | A new thermometer was purchased an placed in the first aid kit. Direct support will do weekly checks to ensure all items are in the first aid kit. Direct support staff will notify their direct supervisor if any items are needed. |
02/02/2024
| Implemented |
| 6400.82(c) | There was no mat or non-slip surface found in the bathtub. | (c) For homes serving one or more individuals who have physical disabilities, at least one sink, one toilet and one tub or shower shall be adapted so that individuals who have physical disabilities have easy access and use.
| A non-slip mat for the shower was purchased the next day. Direct support will do a walk through of the home on all shifts to ensure the home as everything that's needed. Any items needed will be logged and reported to their supervisor. |
02/01/2024
| Implemented |
| 6400.82(f) | There were no clean paper or hand towels in the hallway bathroom.
There was no soap, paper towels, or trash receptable located in individual 1's bathroom. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Paper towels, soap and a trash can were all purchased and put in both bathrooms. Staff will ensure that these items are replenished as needed. If items are needed they will notify their supervisor. |
02/01/2024
| Implemented |
| 6400.113(a) | Fire safety training was not provided for individual. 1. | 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. | All consumers will take an online fire safety training ASAP. |
05/16/2024
| Implemented |
| 6400.144 | Staff stated the nurse administered all psychotropic medications, such as Lithium, Trileptal, Thorazine/chlorpromazine, Klonopin Haloperidol, and Seroquel, and no verification was provided per being requested. | 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 nurse will sign in and out of a medication log when administering medication. |
02/20/2024
| Implemented |
| 6400.144 | It could not be determined if all PRN meds was available, because they were not included on the MAR. Nor was a list of PRN's located at the time of 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.
| Safelift contacted their current pharmacy and requested all PRN medications be added to the MARS. PRN's are currently on all MARS. |
02/01/2024
| Implemented |
| 6400.181(e)(10) | A Lifetime medical history was not found in the record at the time of the inspection. | The assessment must include the following information: A lifetime medical history. | A lifetime medical was comprised immediately of the consumers history. |
02/29/2024
| Implemented |
| 6400.217 | There was no signed copy of release of information found in the record. | 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.
| A release of information policy, including photographs was generated immediately, and all consumers signed. |
03/01/2024
| Implemented |
| 6400.52(a)(1) | Staff 1 did not have the required 24 hours annual training was not completed, 2 hours CPR/First Aid and 2 hours Fire Safety trainings that totaled 19 hours was found.. | The following shall complete 24 hours of training related to job skills and knowledge each year: Direct service workers. | Staff had more than enough training hours. The hours staff 1 had were not in the designated time frame. |
02/01/2024
| Implemented |
| 6400.165(b) | Levetiracetam 500mg to be taken by mouth twice daily-4pm dose was not located in the house at the time of inspection. | A prescription order shall be kept current. | Safelift will order all medications as needed per consumer. Staff will notify supervisors when medications is low. |
02/01/2024
| Implemented |
| 6400.165(c) | Benztropine Mesylate was listed as to be given at 4pm and the inspection was conducted at 2pm, and was initialed by staff 2 that was not present at the time of inspection. | A prescription medication shall be administered as prescribed. | All prescription medications should be administered as prescribed. A practicum will be given to staff 2 to ensure he knows how to administer medication at their proper times. |
01/31/2024
| Implemented |
| 6400.166(a)(13) | MAR did not include name or initials of staff administering medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | Request current pharmacy to add lines for signature and dates to the bottom of each page of the MARS. |
03/01/2024
| Implemented |
| 6400.166(d) | Individual 1 daily vitamin could not be determined on the blister packs when or if medication were being administered daily. Only 2 tablets were removed from the blister pack the time of inspection. | The directions of the prescriber shall be followed. | Place a new order at the pharmacy for a new blister pack of medication. Have direct support start the new pack of medications immediately. |
02/01/2024
| Implemented |
| 6400.169(a) | Staff 1 did not have Medication Administration training as well as annual practicum was not found. | 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). | Staff 1's medication training and annual practicum was located. |
02/01/2024
| Implemented |
| 6400.169(d) | Credentials of medication administration were not provided at the time of inspection. | A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. | Our current med administrator has all of their credentials. This person will be giving med training and practicums moving forward. |
02/01/2024
| Implemented |