| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 20.34 | Access to Individual #1's May 2023 medication administration record was requested but not provided; their current month medication administrations and staff who provided them are indeterminate as such. | The facility or agency shall provide to authorized agents of the Department full access to the facility or agency and its records during both announced and unannounced inspections. The facility or agency shall provide the opportunity for authorized agents of the Department to privately interview staff and clients. | Individual #1 was out of the home with their May medication record at the time of the inspection.
On 5/12/23, the CEO provided the department with individual #1 May 2023 medication record for review. |
05/12/2023
| Implemented |
| 6400.62(a) | Individual #1's ISP indicates they are not poison-safe. Poisonous materials were found unlocked in various places around the property: hand sanitizer on a shelf in the living room; Easy Off oven cleaner spray on top of the refrigerator. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Support staff failed to secure the poisonous materials after cleaning the oven and securing the hand sanitizer.
On 5/11/23, the poisonous materials in the home were locked in a cabinet inaccessible to individual. Staff was re-educated on the proper storing of poisonous materials and individual #1 support plan for the usage of poisonous materials. |
05/11/2023
| Implemented |
| 6400.63(a) | Hot water in the kitchen sink was measured at 147 degrees. In the bathroom sink, it was measured at 150 degrees. | Heat sources, such as hot water pipes, fixed space heaters, hot water heaters, radiators, wood and coal-burning stoves and fireplaces, exceeding 120°F that are accessible to individuals, shall be equipped with protective guards or insulation to prevent individuals from coming in contact with the heat source. | The support staff failed to notify the program manager that the water temperature of the home exceeded 120 degrees.
On 5/11/23, the program manager placed a maintenance request with the leasing office to have the water temperatured lowered for the apatment. The apartment complex maintenance department lowered the water temperature below 120 degrees. Staff was reeducated on testing the hot water of the home. |
05/11/2023
| Implemented |
| 6400.68(b) | Hot water in the shower was measured at 151 degrees. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The support staff failed to notify the program manager that the water temperature of the home exceeded 120 degrees.
On 5/11/23, the program manager placed a maintenance request with the leasing office to have the water temperatured lowered for the apatment. The apartment complex maintenance department lowered the water temperature below 120 degrees. Staff was reeducated on testing the hot water of the home. |
05/11/2023
| Implemented |
| 6400.82(f) | There was no trash can in the 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. | Support staff failed to notify the program manager to purchase a new trash can for the bathroom because the lid was broken.
On 5/11/23 a new trash can was purchased and placed in the bathroom. |
05/11/2023
| Implemented |
| 6400.112(c) | This location 4/2023 fire drill does not state how long it took for the occupants to evacuate the premises. | 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. | The current fire drill form was missing the evacuation time on the form therefore, this information wasn't being documented by staff conducting the fire drill.
On 5/11/23, the program manager was revised agency wide to include the evacuation time on the fire drill on the form. All staff was re-educated on completing the monthly fire drill form. |
05/11/2023
| Implemented |
| 6400.113(a) | Individual #1 has not had an annual 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. | The program manager failed to complete a general fire safety training upon admission for individual #1.
On 5/30/23, Individual #1 and #2 were both trained in general fire safety and smoking safety procedures. |
05/30/2023
| Implemented |
| 6400.141(c)(1) | Individual #1's 4/14/23 physical does not include a review of their previous medical history. | The physical examination shall include: A review of previous medical history. | Support staff failed to review individual #1's physical examination form for completedness prior to leaving the doctor's office resulting in missing information not be recorded on the physical form.
Individual #1 received a new physical exam that was completed on 6/2/2023 that included a review of her medical history. |
06/02/2023
| Implemented |
| 6400.141(c)(6) | Individual #1's 3/14/23 physical does not include a tuberculosis screening, nor has verification been provided to show that one has been completed in the last 2 years. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Support staff failed to review individual #1's physical examination form for completedness prior to leaving the doctor's office resulting in missing information not be recorded on the physical form.
On 5/12/23 the program manager scheduled individual #1 a new appointment for a physical exam to have the paperwork completed in its entirety.
On 6/2/23 individual #1 had a TB test screening completed in which the results were documented on the physical exam form. |
06/02/2023
| Implemented |
| 6400.141(c)(7) | Individual #1 4/14/23 physical did not include a gynecological exam. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Support staff failed to review individual #1's physical examination form for completedness prior to leaving the doctor's office resulting in missing information not be recorded on the physical form.
On 5/12/23 the program manager scheduled individual #1 a new appointment for a physical exam to have the paperwork completed in its entirety. Individual #1 received a new physical exam that was completed on 6/2/2023. |
06/02/2023
| Implemented |
| 6400.141(c)(10) | Individual #1 4/14/23 physical does not state if they are free of communicable diseases. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | Support staff failed to review individual #1's physical examination form for completeness prior to leaving the doctor's office resulting in missing information not be recorded on the physical form.
On 5/12/23 the program manager scheduled individual #1 a new appointment for a physical exam to have the paperwork completed in its entirety. On 6/2/23 Individual #1 had a physical exam and form completed to include free of communicable diseases. |
06/02/2023
| Implemented |
| 6400.141(c)(13) | Individual #1's 4/14/23 physical did not include allergies or contraindicated medications. | The physical examination shall include: Allergies or contraindicated medications. | Support staff failed to review individual #1's physical examination form for completedness prior to leaving the doctor's office resulting in missing information not be recorded on the physical form.
On 5/12/23 the program manager scheduled individual #1 a new appointment for a physical exam to have the paperwork completed in its entirety. Individual #1 received a new physical exam and form completed on 6/2/23 to include the list of allergies and.or contraindicated medications. |
06/02/2023
| Implemented |
| 6400.141(c)(14) | Individual #1 4/14/23 physical does not include medical information pertinent to diagnosis and treatment in case of emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Support staff failed to review individual #1's physical examination form for completedness prior to leaving the doctor's office resulting in missing information not be recorded on the physical form.
On 5/12/23 the program manager scheduled individual #1 a new appointment for a physical exam to have the paperwork completed in its entirety. Individual #1 received a new physical exam and form completed on 6/2/23 that included diagnosis and treatment in case of an emergency. |
06/02/2023
| Implemented |
| 6400.141(c)(15) | Individual #1 4/14/23 physical does not include special instructions for the individual's diet. | The physical examination shall include:Special instructions for the individual's diet. | Support staff failed to review individual #1's physical examination form for completedness prior to leaving the doctor's office resulting in missing information not be recorded on the physical form.
On 5/12/23 the program manager scheduled individual #1 a new appointment for a physical exam to have the paperwork completed in its entirety. Individual #1 received a new physical exam and form completed on 6/2/23 to include the individual's diet. |
06/02/2023
| Implemented |
| 6400.151(c)(2) | Staff #1 did not have a tuberculosis test completed with their last physical on 3/7/23, nor did they have any documented tuberculosis screening in their file since their 3/13/23 hire date. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | The agency failed to receive a copy of staff #1 TB test results that was conducted by their own doctor.
Staff #1 provided documentation of having a TB test and the results to the agency. The CEO placed a copy of the report in Staff #1's employee file. |
05/26/2023
| Implemented |
| 6400.151(c)(3) | Staff #1's 3/7/23 physical does not state if they are free of communicable diseases.
Staff #2's 2/14/23 physical does not state if they are free of communicable diseases. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | Support staff received a physical exam using an outside agency and not the agency preferred occupational health provider resulting in the attestation of being free of communicable disease not being documented on the form.
Staff #1 received written documentation for their doctor of being free of communicable disease. The CEO placed a copy of the report in Staff #1 employee file. |
05/26/2023
| Implemented |
| 6400.217 | Individual #1 does not have a signed release of information document in their 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.
| ndividual #1 signed released of information was improperly filed away in their main file record binder.
On 5/12/23, the program manager completed an audit of individual #1 main file binder. The completed and signed individual rights attestation form for individual #1 was filed correctly in their main file |
05/12/2023
| Implemented |
| 6400.18(i) | Individual #1 has two open incidents that have not been resolved within 30 days and there is not an approved extension in place. These incidents are ID# 9030048 with a 4/22/22 discovery date and the other is ID# 9025086 with a 5/15/22 discovery date. | 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 point person failed to continously check the status of open EIM cases and resolve them within 30 days of discovery.
The agency point person was re-educated on the incident management requirements to resolve incidents within 30 days of discovery. The point person |
06/04/2023
| Implemented |
| 6400.34(b) | Individual #1 has not signed an individual rights page indicating that they have been informed of their individual rights. | The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights. | Individual #1 signed released of information was improperly filed away in their main file record binder.
On 5/12/23, the program manager completed an audit of individual #1 main file binder. The completed and signed individual rights attestation form for individual #1 was filed correctly in their main file |
05/12/2023
| Implemented |
| 6400.165(b) | Individual #1s April 2023 medication administration record (MAR) indicates two 100 mg. tablets of trazodone are to be taken at bedtime. In their medication box, two blister packs of this medication with this administration instruction were found. However, a third trazodone blister pack with 50 mg. tablets with instructions to take one at bedtime was also found, which is not reflected on the MAR. | A prescription order shall be kept current. | The nurse failed to transcribe the current prescribed order for individual #1 Trazadone order on the medication record.
On 5/11/23 individual #1 medication record was updated to reflect the current order for Trazadone 250mg at bedtime. |
05/11/2023
| Implemented |
| 6400.165(g) | Individual #1 takes at least one prescribed psychotropic medication but is not having their medications reviewed every 3 months by a licensed physician. | 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. | The program manager failed to schedule individual #1 a psychotropic medication review within the three month time frame.
On 5/11/23, the program manager scheduled individual #1 an appointment for a pyschotropic medication review. Inidividual #1 has a scheduled appointment for June 6th, 2023 for a psychotropic medication review. |
05/31/2023
| Implemented |
| 6400.166(a)(13) | Individual #1's 6PM dosage of prescribed medication clonidine was not signed for on 4/30/23. Their 8PM dosage of trazodone was also not signed for on 4/30/23. | 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. | The nurse failed to transcribe the current prescribed order for individual #1 Trazadone order on the medication record. Support staff failed to notify the supervisor of the medication documentation error.
On 5/11/23 the CEO re-educated staff on reporting medication documentation errors to a supervisor immediately upon discovery. |
05/11/2023
| Implemented |