| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | (Repeat from 3/6/23 and 1/17/24) Individual #1's financial record is not current and up to date. There were numerous math errors in the month of June alone. The ending balance did not match the actual cash-on-hand. | 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. | Each staff was trained on 6-19-24 on how to log money and receipts onto the transaction forms correctly. They were also told to use a calculator instead of using their heads to calculate the money. |
06/29/2024
| Implemented |
| 6400.67(a) | At the time of the inspection, the blinds in the living room and in Individual #1's bedroom had broken slats. | Floors, walls, ceilings and other surfaces shall be in good repair. | Maintenace was notified the day of unannounced visit and the next day the two blinds were replaced. To prevent this from happening again, or the cat climbing the blinds and breaking them, an opaque window film was purchased and delivered on 6-28-24. It will be put on the windows on 7-1-24 by the director. |
07/05/2024
| Implemented |
| 6400.144 | (Repeat from 1/17/24) On 1/24/24, it was recommended that Individual #1 drink 64 ounces of water a day. This is not being tracked. Whenever Individual #1 has testing completed, for example a sleep study, MRI, CT scan etc, the provider does not obtain documentation of the medical appointment. Staff has no way of knowing the results or recommendations. | 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 staff have been tracking a food diary for the PCP for this individual already. The staff will be completing a water/Liquid tracking form for this individual. The tracking form will be collected at the end of the month and be kept in the file at the office. As for testing and appointments, the PS/RN will be attending most if not all of the individuals' appointments and will ask for additional copy of the visit summary, so the family can have a copy and we can have a copy to review all documentation. For MRI's, CT scans, etc. the PS/Director will email the PCP's nurse case manager for a copy of the results for review and the file. |
07/01/2024
| Implemented |
| 6400.181(e)(1) | Individual #1's most recent assessment completed on 2/15/24 does not document their strengths or needs. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | The director went thru the regulations with the two PS's on 6-26-24 to make sure that each regulation is a subsection in the assessment so that no part is missed. We also wrote up a new Program Assessment Template for any new individuals coming into the program in the future. The individual's assessment was redone on 6-26-24 to add in the additional sections and their information. |
06/26/2024
| Implemented |
| 6400.181(e)(11) | Individual #1's most recent assessment completed on 2/15/24 does not document if Individual #1 has had a psychological evaluation. | The assessment must include the following information: Psychological evaluations, if applicable. | The director went thru the regulations with the two PS's on 6-26-24 to make sure that each regulation is a subsection in the assessment so that no part is missed. We also wrote up a new Program Assessment Template for any new individuals coming into the program in the future. The individual's assessment was redone on 6-26-24 to add in the additional sections and their information. |
06/26/2024
| Implemented |
| 6400.18(i) | Individual #2 had an exploitation investigation begin 1/18/24 and a neglect investigation begin 2/20/24. As of 6/18/24, neither investigation is complete. Individual #1 had a neglect investigation begin 3/23/24. This investigation is not complete. | The home shall finalize the incident report through the Department's information management system or on a form specified by the Department within 30 days of discovery of the incident by a staff person unless the home notifies the Department in writing that an extension is necessary and the reason for the extension. | The director will complete all open EIM's and investigations that are currently open by 7-9-24. During this time the director will show the new program specialist/RN how to complete the EIM's for future needs. The new program specialist/RN will also be sent to an upcoming investigator training class to help with investigations. |
07/09/2024
| Implemented |
| 6400.51(b)(5) | Staff #3, Staff #4, Staff #6, Staff #7, Staff #8, Staff #9, Staff #10, and Staff #11 did not receive Person Specific training that had an in-person component with the individuals present. Staff were tasked with reading the ISPs independently as part of their training. | The orientation must encompass the following areas: Job-related knowledge and skills. | On 6-24-26 each PS met with the director to explain that all training for each individual is to be done in person, this also includes all staff meetings. All training will be in person and documented that it was completed in person. There will also be a new orientation training process starting on 8-1-24. |
07/01/2024
| Implemented |
| 6400.52(c)(5) | Staff #1 did have a general positive approaches/behavior support training, but no individual specific behavior support training was provided for any of the individuals behavior plans. It is unable to be determined if the individual (s) was present for a portion of the behavior support training or if a person specific behavior support training took place. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | An individual behavior plan test will be made for each individual that has a behavior plan so that it is individualized and each staff will have to complete it after the behavior plan has been reviewed with them. |
07/12/2024
| Implemented |
| 6400.52(c)(6) | Staff #1's ISP training for the individuals did not include an in-person component. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | On 6-24-26 each PS met with the director to explain that all training for each individual is to be done in person, this also includes all staff meetings. All training will be in person and documented that it was completed in person. There will also be a new orientation training process starting on 8-1-24. |
07/01/2024
| Implemented |
| 6400.165(g) | (Repeat from 1/17/24) Individual #1 is prescribed psychotropic medications. No quarterly psych med reviews have occurred. | 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. | An appointment has been made with this individual's PCP who oversees the psych medications which will be held on 7-11-24 where the correct form for medication review that was approved in Jan 2024 will be used. The director emailed the PCPs nurse case manager letting them know that the psych medications that this individual is on needs to be completed every quarter. The PS/Director will make sure that this is done, and the correct form is utilized during the appointment. |
07/11/2024
| Implemented |
| 6400.167(a)(1) | Individual #1 did not receive their Loratadine on 5/31/24. Individual #1's MAR did not document that Individual #1 received their Loratadine on 6/7/24 or their Polyethylene Glycol on 6/15/24. | Medication errors include the following: Failure to administer a medication. | The PS will be reviewing the MAR's and the blister packs for compliance each day that they are on shift there. The director was able to get a bowel protocol for this individual and each staff will be trained in person on the bowel protocol by 7-5-24. |
07/01/2024
| Implemented |