| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | A self-assessment was not completed for the home. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. | December 17,2024, the self-assessment was not completed in the correct amount of time which is 3 to 6 months prior to the expiration date of our compliance. We have put on all calendars (electronic and physical) to submit self-inspection in the correct time. |
12/17/2024
| Implemented |
| 6400.22(d)(2) | At the time of the 12/18/24 inspection, the financial record for December for individual #1 was documented that the Individual's cash balance should be $382.32, however, there was $384.85 in the home. | (2) Disbursements made to or for the individual.
| Individual#1 had gone to dinner with a staff member and tipped the waiter 2.53 dollars, upon returning back from dinner the supervisor refunded the individual #1 the 2.53 that was used to tip. The supervisor was advised by the inspector that it was ok for individuals to tip whenever they go out for dinner. |
12/23/2024
| Implemented |
| 6400.113(a) | The fire safety training paper for Individual #1 was not signed or have a date of completion to indicate if the individual completed the fire safety training. | 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. | On the date of admission, the individual #1 watched the fire safety training video but staff forgot to have the individual sign the fire safety training record. Individual #1 watched the fire safety training video again on 12/21/2024 and signed a new fire safety training record |
12/21/2024
| Implemented |
| 6400.141(c)(3) | Individual #1's 9/30/24 annual physical examination does not include immunization information. | 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 immunization record was attached onto the physical form. |
12/20/2024
| Implemented |
| 6400.141(c)(15) | The special diet instructions section of individual #1's 9/30/24 annual physical examination is blank. | The physical examination shall include:Special instructions for the individual's diet. | Individual # 1 physical examination paperwork has been dropped off at the doctors office for it to be completed. |
12/23/2024
| Implemented |
| 6400.144 | At the time of the inspection on 12/18/24, PRN medications Docusate Sodium 100 mg and Triamcinolone Cream for individual #1 were not available in the home.
Individual #1's 11/14/24 Individual Support Plan indicates that their water intake is to be monitored as the individual can drink an excessive amount, causing them to deplete their electrolytes and vomit. There is no plan in place to ensure this monitoring is occurring. | 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.
| December 23, 2024- We were able to get the Docusate Sodium 100 mg and Triamcinolone Cream that are PRN medications from the pharmacy. They are now available in the medicine cabinet at all times for as needed purposes. A water tracking form was developed to track the individuals water intake through our water intake to avoid excessive water consumption which could lead to vomiting. Staff were trained on the new form. |
12/23/2024
| Implemented |
| 6400.145(1) | The medical plan for Individual #1 did not have the hospital or source of health care that will be used in an emergency. | The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. | Individual #1 medical plan was updated to include the hospital or source of healthcare that will be used incase of an emergency. |
12/20/2024
| Implemented |
| 6400.181(a) | Individual #1's date of admission is 10/1/24. At the time of the 12/17/24 inspection, the individual's initial assessment should have been complete. While the provider completed an assessment, it did not address many of the areas required by 6400.181e1-14 and was largely incomplete. | 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. | The assessment has been updated to included all requirements as per 6400.181(a) |
12/23/2024
| Implemented |
| 6400.211(b)(1) | Individual #1's emergency information does not include the name, telephone number, and address of who is to be contacted in case of an emergency. | Emergency information for each individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.
| Individual #1's contacts have been updated to include the name, telephone number, and address of who is to be contacted in case of an emergency. |
12/23/2024
| Implemented |
| 6400.165(f) | Individual #1 is prescribed medication for the treatment of a diagnosed psychiatric illness. The provider agency does not have a plan in place to address the social, emotional, and environmental needs of the individual related to the 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. | December 23,2024- A seen plan has been put in place and includes all of the individuals psychiatric medication and addresses the S-ocial E-motional E-nviroemntal N-eeds for the individual. |
12/23/2024
| Implemented |
| 6400.165(g) | Individual #1's 10/11/24 psychiatric medication review did not include the names of the medication or the necessary dosage. | 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. | When individual #1 went for their doctor's appointment an attached list of their current medication was attached to the psychiatric medication review form however the list of medication was detached from the medication review form when filed. |
12/23/2024
| Implemented |
| 6400.166(a)(4) | At the time of the inspection on 12/18/24, for individual #1, the PRN medication Senna 8.6 mg was found in the home, but it was not listed on the MAR. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | Individual #1's Senna 8mg was removed from the medication box and returned to the pharmacy due to it being discontinued. |
12/19/2024
| Implemented |
| 6400.213(1)(i) | Individual #1's demographic information page does not include their date of admission.
The photograph in Individual #1's record is not dated. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate, Social Security number, and a current, dated photograph. | Individual #1's demographic page was updated to include the date of admission and a dated photograph. |
12/19/2024
| Implemented |