| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | At the time of inspection there was no up to date financial record noting funds received by or deposited with the home for Individual #1 in the home. File review noted that there were no up to date financial records for September, October, and November.
The end balance of April 2024 was .28 and the begin balance of May recorded as $1.10. Reason for the discrepancy could not be determined. | 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. | Individual tracking for financials was immediately implemented in the home. The individual's financials were audited and brought up to date through November 2024. Financials are currently being audited and reviewed for December 2024. |
12/30/2024
| Implemented |
| 6400.22(d)(2) | At the time of inspection there was no up to date financial record for Individual #1 noting disbursements made to or for the individual in the home. File review noted that there were no up to date financial records for September, October and November. | (2) Disbursements made to or for the individual.
| Individual tracking for financials was immediately implemented in the home. The individual's financials were audited and brought up to date through November 2024. Financials are currently being audited and reviewed for December 2024. |
12/30/2024
| Implemented |
| 6400.64(b) | There was evidence of infestation of rodents in the home at the time of inspection. Approximately ten small black pellets that appeared to be mouse droppings were found under the kitchen sink and in the bathroom vanity cabinet in the bathroom attached to the bedroom of Individual #1. | There may not be evidence of infestation of insects or rodents in the home. | The areas of concern were immediately cleaned and sanitized. |
12/05/2024
| Implemented |
| 6400.68(c) | Documentation of water samples collected on 2/22/24, 5/10/24 and 8/2/24 was provided. There was no documentation to support that the water sample was taken in November as required. | A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept. | A coliform test was completed for the home on 11/7/2024. |
12/05/2024
| Implemented |
| 6400.104 | Individual #1 moved into the home on 5/22/24 there was no documentation that notification to the fire department occurred as required. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| A fire letter was sent to the local department regarding the change on September 24, 2024. |
12/05/2024
| Implemented |
| 6400.106 | Documentation of furnace cleaning was provided for 1/6/23 then again on 2/5/24. This is beyond the annual time frame and grace period. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| A furnace inspection and cleaning was conducted at the home on 11/20/2024. |
12/05/2024
| Implemented |
| 6400.144 | Individual #1 was seen by their Gastroenterologist on 9/20/24 and was ordered to "obtain stool sample." A stool sample was not obtained. A letter from the Gastroenterologist dated 12/2/24 noted "At his last office visit he was ordered a stool test to rule out any bacteria infections." This test is no longer needed as his symptoms have inporoved on there own." The stool sample was needed when ordered but not obtained. | 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 individual¿s gastroenterologist was contacted on 12/2/24, upon discovery of the missed test, to determine if the stool sample was still required and the physician discontinued the order. Staff in the home were retrained on the administration of non-oral medications on 12/9/24. |
12/02/2024
| Implemented |
| 6400.19(b) | On 8/30/24 Incident #9476446 was entered for financial exploitation of Individual #1. The investigation concluded that $92.50 was missing from the individual's finances and that staff members were "not routinely verifying current balance of cash on hand and merely copying the previous balance entered into the running total." The incident report notes that corrective action completed on 10/9/24 to be "Retrain appropriate staff on existing policy and/or procedure and evaluate effectiveness." Further notation indicates that "Staff retrained on proper protocol for cash on hand tracking and receipts" completed on 10/9/24. At the time of inspection on 12/4/24 there were no up to date financial records of Individual #1's cash on hand and .75 in pennies was at the home. Additionally, there were no up to date financial records for cash on hand covering the months of September, October, November and December. The provider did not properly implement, ensure completion of the plan of correction or evaluate their plan for effectiveness as written. | The home shall monitor an individual's risk for recurring incidents and implement corrective action, as appropriate. | The individuals financials were update to the current date on 12/30/24. |
12/30/2024
| Implemented |
| 6400.32(c) | Individual #1 was neglected as their bowel specific medications were not administered correctly over an eight-month period. As documented in their Individual Support Plan last updated on 11/21/24, Individual #1 is diagnosed with Constipation and Irritable Bowel Syndrome. Individual #1 is prescribed Cholestyram Pow to be administered as "Dissolve 1 packet in 8oz of liquid and drink by mouth once every day for chronic constipation and overflow." At the time of inspection, a bag containing 27 of the 30 packets delivered on 4/15/24 was in use for Individual #1. If administered as prescribed the medication would have required a refill on or about 5/15/24. An additional bag of the medication was found in the home at the time of inspection. The pharmacy label noted a fill date of 11/27/24 and 30 packets. All 30 packets were in the bag. Staff #2 noted that they were not aware of any refusals or out of program days and the medication had been marked as administered each day up to and including 12/14/24. There were no pharmacy records to support that additional packets of the medication had been delivered between 4/15/24 and 11/27/24. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | Staff in the home were retrained on the administration of non-oral medications on 12/9/24. |
12/09/2024
| Implemented |
| 6400.34(a) | There was no documentation to support that Individual #1 had been informed of their rights. | 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. | Individual was informed of and signed a form informing him of his rights on 12/27/24. |
12/27/2024
| Implemented |
| 6400.165(c) | Individual #1 is prescribed Fluticasone Propionate Nasal Spray to be administered one spray in each nostril once daily. The bottle in use at the time of inspection on 12/4/24 was dated 8/14/24 and appeared to be full. The manufacturer label indicates that the bottle contained 120 sprays. A 60-day supply as ordered. Administered as prescribed a new bottle should have been stated on or about 10/14/24. An unopened new bottle dated 10/10/24 was also in the home at the time of inspection. Medication logs for December 2024 were initialed as administered. Staff #2 noted that they were not aware of any refusals or out of program days. There were no pharmacy records to support that additional bottles had been delivered between 8/14/24 and 10/10/24.
As documented in their Individual Support Plan last updated on 11/21/24, Individual #1 is diagnosed with Constipation and Irritable Bowel Syndrome. Individual #1 is prescribed Cholestyram Pow to be administered as "Dissolve 1 packet in 8oz of liquid and drink by mouth once every day for chronic constipation and overflow." At the time of inspection, a bag containing 27 of the 30 packets delivered on 4/15/24 was in use for Individual #1. If administered as prescribed the medication would have required a refill on or about 5/15/24. An additional bag of the medication was found in the home at the time of inspection. The pharmacy label noted a fill date of 11/27/24 and 30 packets. All 30 packets were in the bag. Staff #2 noted that they were not aware of any refusals or out of program days. There were no pharmacy records to support that additional packets had been delivered between 4/15/24 and 11/27/24. | A prescription medication shall be administered as prescribed. | Staff in the home were retrained on the administration of non-oral medications on 12/9/24. |
12/09/2024
| Implemented |
| 6400.181(f) | There was no documentation to support that the assessment had been provided to the plan team members at least 30 calendar days prior to the individual plan meeting held on 5/14/24. The assessment available at the time of inspection was dated 11/27/24. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Individual¿s current skills assessment was provided to his current Supports Coordinator on 12/30/2024. |
12/30/2024
| Implemented |