| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(2) | As of 6/25/2024, Individual #1's June 2024 "Individual Petty Cash Tracker Form", had a balance of $17.50. On 6/26/2024, there was $2.47 in cash was present in the home for Individual #1. Direct Service Worker #2 revealed that Individual #1, who was not present in the home, had $13.00. This withdrawal that was given directly to Individual #1 was not recorded on the Individual #1's June 2024 "Individual Petty Cash Tracker Form." | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: For a withdrawal when the individual is given the money directly, the record shall indicate that funds were given directly to the individual. | Freedom Community Connections staff is retrained on using the petty cash form to ensure documentation is completed correctly and the money is counted accurately when assisting individual in managing their funds. All receipts are submitted to the rep payee on a monthly basis. |
07/12/2024
| Not Implemented |
| 6400.62(a) | In the safety precaution section of Individual #1's individual plan that was last updated on 6/25/24 reads, "All poisons are kept locked except for non-toxic hand soap". On 6/26/24 at 1:21PM, a 1-gallon bottle of OdoBan disinfectant with instructions to contact poison control if ingested was unlocked and accessible under the kitchen sink. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Freedom Community Connections Site Supervisor retrieve items immediately in the presence of the inspectors during licensing on 6/26/2024 and placed it in the locked chemical cabinet in the staff office. Staff was retrained on storage of all chemical to ensure the health and safety of the participant is maintained. The program specialist will reassess whether the participant can be safe with chemicals as precautions were taken based off of historical information. |
08/10/2024
| Implemented |
| 6400.76(a) | On 6/26/24 at 1:04PM. the louvered closet doors in Individual #1's bedroom had approximately eleven slats that were askew and pulling away from the door frame. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Freedom Community Connections submitted a maintenance request at the time of discovery by the inspectors during licensing. A closet door was purchased and was replaced on 7/8/24. |
07/08/2024
| Not Implemented |
| 6400.80(a) | Directly outside the basement door in the rear of the home is an area approximately two feet by two feet of dirt and rocks. In addition, there is a concrete slab between the area of dirt and the basement floor that is raised approximately two inches. These areas of the walkway pose a slipping and tripping hazard at the rear egress of home. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | Freedom Community Connections submitted a maintenance request on 6/27/2024 for walkway repair for the outside basement door in the rear of the home. A work order has been initiated and FFC is waiting on a quote to complete the request. |
08/09/2024
| Not Implemented |
| 6400.112(c) | The written fire drill record on 4/9/24 did not include the time of the fire drill. A written fire drill record on 5/11/24 did not include the amount of time it took for evacuate. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Freedom Community Connections staff will be retrained on fire drill documentation on 7/12/24 to ensure they are documenting correctly on the fire drill record when a drill has been conducted. |
07/12/2024
| Not Implemented |
| 6400.141(c)(11) | Individual #1's physical examination completed 2/16/24 did not include health maintenance needs, medication regimen and the need for blood work at recommended intervals. | 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. | Freedom Community Connections annual physical form was updated on 7/2/2024 to include individual¿s health maintenance needs, and medication regimen. All old forms were shredded to ensure old forms are not being utilized during appointments. |
07/02/2024
| Not Implemented |
| 6400.141(c)(14) | Individual #1's physical examination completed 2/16/24 did not include medication information pertinent to diagnosisand treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Freedom Community Connections annual physical form was updated on 7/2/2024 to include i medication information pertinent to diagnosisand treatment in case of an emergency. All old forms were shredded to ensure old forms are not being utilized during appointments. |
07/02/2024
| Not Implemented |
| 6400.181(a) | Individual #1, date of admission 3/12/24 did not have an initial assessment completed until 5/17/24. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Freedom Community Connections admission date for the individual was 3/12/2024 and not 12/16/23. The previous provider completed the assessment dated 12/16/23. The assessment was completed on 5/17/2024, the individual was hospitalized for about 3 weeks after admission, the other provider¿s assessment was used as it met compliance with regulations. Program Specialist will ensure the initial assessment is completed within 60 days of admission. Program Specialist was retrained on their job description. |
07/08/2024
| Implemented |
| 6400.163(d) | On 6/26/24 at 1:08PM, a bottle of People's Choice Women's daily with iron, a bottle of ValuHealth acetaminophen 500mg caplets were unlocked and accessible in the vanity in the bathroom on the first floor of the home. On 6/26/24 at 1:09PM, a People's Choice Probiotic Acidophilus capsules was in the closet in the bathroom on the first floor of the home. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | Freedom Community Connections disposed of all the medications that were not prescribed by the doctor. Site supervisor followed up with the individual PCP to inquire about getting orders for the medication that the individual purchased for her use. The PCP send prescriptions to the pharmacy for individual to take in replacement of the medication that were disposed. The medication is kept in the locked container in the staff office. |
07/19/2024
| Implemented |
| 6400.163(h) | Mupirocin 2% ointment with instructions to apply topically three times daily for seven days was prescribed to Individual #1 beginning on 5/14/2024. As of 6/26/2024, this medication was not disposed of and remained in the home. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Freedom Community Connections did not administer any medication beyond the timeframe listed per the MAR. Medication was discontinued in the presence of the inspectors by the medication trainer and then disposed on 6/26/2024. |
06/26/2024
| Implemented |
| 6400.165(c) | Acetaminophen 500mg tablet, take one tablet by mouth every 6 hours as needed for mild pain for up to 10 days prescribed to Individual #1 was administered to Individual #1 between 6/1/24 and 6/22/24. | A prescription medication shall be administered as prescribed. | Freedom Community Connections did not administer any medication beyond the timeframe listed per the MAR. Medication was discontinued in the presence of the inspectors by the medication trainer and then disposed on 6/26/2024. Freedom Community Connection will reach out to Dr to get clearer instruction so as to provide medication in an efficient manner. |
06/26/2024
| Implemented |
| 6400.165(f) | Individual #1 is prescribed Haloperidol for agitation and psychosis, Oxcarbazepine for mood stabilization, and Perphenazine for agitation and impulse control. Individual #1 written protocol as part of the individual plan to address the social, emotional, environmental needs of the individual related to the symptoms of the psychiatric illness. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | Freedom Community Connections will develop and create a SEEP plan to address social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. |
08/09/2024
| Implemented |
| 6400.166(b) | Melatonin 3mg tab, take one tablet by mouth at bedtime, prescribed Individual #1 was not initialed as administered on 6/20/24 at 8:00PM. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Freedom Community Connections will complete a medication review with staff to ensure that they are following medication guidelines per training. |
07/12/2024
| Implemented |
| 6400.167(a)(4) | Individual #1 is prescribed Haloperidol Dec 100 mg/ml vial with instructions to inject 150mg (1.5 ML) intramuscularly once every 30 days, last dose 5/15/24, given at group home for agitation and psychosis. This medication was not administered on 6/15/24. There was a note on the back of the June 2024 medication administration record written on 6/15/24 that stated the medication was missed due to not needle on site. There is another note that was written on 6/17/24 at 11:00PM, that states that the needle was purchased. This medication was then initialed on the June 2024 medication administration record as administered on 6/15/24 at 5:00PM. | Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time. | Freedom Community Connections will ensure the contracted nurse has all the supplies needed to administer the medication in a timely manner. The site supervisor will contact the nurse 3 days prior to the medication administration date to ensure all supplies needed are available and will place it on the calendar. |
07/12/2024
| Implemented |
| 6400.192 | The home is locking sharp objects and knives in the home. The home has not developed and implemented restrictive procedures for Individual #1. In the general health and safety risks of Individual #1's individual plan, last updated 6/25/24 reads, "Sharp objects and knives are locked away in the home due to [Individual #1's] aggressive tendencies". | The home shall develop and implement a written policy that defines the prohibition or use of specific types of restrictive procedures, describes the circumstances in which restrictive procedures may be used, the staff persons who may authorize the use of restrictive procedures and a mechanism to monitor and control the use of restrictive procedures. | Freedom Community will immediately reassess the need for locked sharps as they were only locked due to precautionary measures in collaboration with the behavior specialist. If sharps are determined to need to be lock the BSP will develop a restrictive procedure and bring it to the Human Rights Committee for approval. |
08/09/2024
| Not Implemented |