Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.141(b) | Physical exam FOR INDIVIDUAL 2 dated 8/18/23, was not signed by a physician. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | The staff responsible (former program specialist) was disciplined and is no longer with the organization. Upon her departure the organization learned many of the infractions found during this licensing inspection were intentional. The findings of this licensing inspection and subsequent findings regarding this former staff prompted a restructuring of the organization.
The site manager initiated the scheduling of another physical examination for correction. However, individual 2 has relocated and is no longer at the residence. |
04/03/2024
| Implemented |
6400.141(c)(3) | Immunizations not recorded on physical exam for individual 1. | 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. | The staff responsible (former program specialist) was disciplined and is no longer with the organization. Upon her departure the organization learned many of the infractions found during this licensing inspection were intentional. The findings of this licensing inspection and subsequent findings regarding this former staff prompted a restructuring of the organization.
The site manager scheduled another physical examination for this individual for correction (appointment is scheduled for 2/16/24). |
02/23/2024
| Implemented |
6400.141(c)(10) | Physical exam dated 3/1/23, for individual 1 If the individual is free from communicable disease(s) was left blank on physical exam. | 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. | The staff responsible (former program specialist) was disciplined and is no longer with the organization. Upon her departure the organization learned many of the infractions found during this licensing inspection were intentional. The findings of this licensing inspection and subsequent findings regarding this former staff prompted a restructuring of the organization.
The site manager scheduled another physical examination for this individual for correction (appointment is scheduled for 2/16/24). |
02/23/2024
| Implemented |
6400.141(c)(14) | Information pertinent to diagnosis in case of an emergency-left blank for individual 1.. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The staff responsible (former program specialist) was disciplined and is no longer with the organization. Upon her departure the organization learned many of the infractions found during this licensing inspection were intentional. The findings of this licensing inspection and subsequent findings regarding this former staff prompted a restructuring of the organization.
The site manager scheduled another physical examination for this individual for correction (appointment is scheduled for 2/16/24). |
02/23/2024
| Implemented |
6400.142(f) | It was not documented that the individual 1 had achieved dental hygiene independence.
There was no dental hygiene plan for individual 2 found in the record. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | The staff responsible (former program specialist) was disciplined and is no longer with the organization. Upon her departure the organization learned many of the infractions found during this licensing inspection were intentional. The findings of this licensing inspection and subsequent findings regarding this former staff prompted a restructuring of the organization.
The new program specialists have been directed to construct a new dental hygiene plan for individual 1 following his annual dental appointment (appointment is scheduled for 3/8/24). |
03/15/2024
| Implemented |
6400.142(g) | There was no dental hygiene plan updated annually for individual 1.
There was no dental hygiene plan updated annually for individual 2. | A dental hygiene plan shall be rewritten at least annually. | The staff responsible (former program specialist) was disciplined and is no longer with the organization. Upon her departure the organization learned many of the infractions found during this licensing inspection were intentional. The findings of this licensing inspection and subsequent findings regarding this former staff prompted a restructuring of the organization.
The new program specialists have been directed to construct a new dental hygiene plan for individual 1 following his annual dental appointment (appointment is scheduled for 3/8/24). |
03/15/2024
| Implemented |
6400.142(h) | There was no dental hygiene plan for individual 1 found in record at inspection.
There was no dental hygiene plan for individual 2 found in record at inspection. - | The dental hygiene plan shall be kept in the individual's record. | The staff responsible (former program specialist) was disciplined and is no longer with the organization. Upon her departure the organization learned many of the infractions found during this licensing inspection were intentional. The findings of this licensing inspection and subsequent findings regarding this former staff prompted a restructuring of the organization.
The new program specialists have been directed to construct a new dental hygiene plan for individual 1 following his annual dental appointment (appointment is scheduled for 3/8/24). The plan will be kept in the individual¿s programming records. |
03/15/2024
| Implemented |
6400.152(b) | The physician did not indicate on staff 1 was free of communicable diseases on the physical form. | Written authorization from a licensed physician shall include a statement that the person will not pose a serious threat to the health, safety or well-being of the individuals and specific instructions and precautions to be taken for the protection of the individuals at the home. | The staff responsible (former program specialist) was disciplined and is no longer with the organization. Upon her departure the organization learned many of the infractions found during this licensing inspection were intentional. The staff intentionally used an outdated staff physical form and failed to ask the practitioner to ¿write-in¿ that she was free of communicable diseases. The findings of this licensing inspection and subsequent findings regarding this former staff prompted a restructuring of the organization. |
04/03/2024
| Implemented |
6400.181(a) | Individual 2's annual assessment was not completed within required timeframe 7/13/22-8/5/23. | 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 staff responsible (former program specialist) was disciplined and is no longer with the organization. Upon her departure the organization learned many of the infractions found during this licensing inspection were intentional. The findings of this licensing inspection and subsequent findings regarding this former staff prompted a restructuring of the organization.
Individual #2 relocated and is no longer with the residence. |
04/03/2024
| Implemented |
6400.181(c) | The assessment dated 6/5/23, for individual 1 does not include what the assessment was based on.
The assessment for individual 2 does not include what the assessment was based on. | The assessment shall be based on assessment instruments, interviews, progress notes and observations. | The staff responsible (former program specialist) was disciplined and is no longer with the organization. Upon her departure the organization learned many of the infractions found during this licensing inspection were intentional. The findings of this licensing inspection and subsequent findings regarding this former staff prompted a restructuring of the organization.
Individual #2 relocated and is no longer with the residence. The program specialists will review the current annual assessment and related documents, composing a new assessment for Individual #1. |
04/03/2024
| Implemented |
6400.181(e)(14) | The ability to swim was not included in the assessment for individual 2. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | The staff responsible (former program specialist) was disciplined and is no longer with the organization. Upon her departure the organization learned many of the infractions found during this licensing inspection were intentional. The findings of this licensing inspection and subsequent findings regarding this former staff prompted a restructuring of the organization.
Individual #2 relocated and is no longer with the residence. |
04/03/2024
| Implemented |
6400.18(j)(1) | The following incidents for individual 2 are still open and there are no documentation provided to indicate an extension was asked to ODP. | The home shall provide the following information to the Department as part of the final incident report: Additional detail about the incident. | The program director requested extensions from the AE, who extended the incidents as far as they could.
The program director will call ODP to extend the incidences for final section submission. |
02/15/2024
| Implemented |
6400.34(a) | The home has not informed and explained the individual's rights and the process to report a rights violation annually. Last signed copy was at admission 5/1/17.Same for both individuals 1 and 2 since 2012.
Individual 2's rights last completed 4/23/12. | 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. | The staff responsible (former program specialist) was disciplined and is no longer with the organization. Upon her departure the organization learned many of the infractions found during this licensing inspection were intentional; the organization has reasons to believe the former staff removed annual copies of the residents' rights forms, either missing or forgetting about the admissions packet. The findings of this licensing inspection and subsequent findings regarding this former staff prompted a restructuring of the organization.
Individual #2 relocated and is no longer with the residence. The house manager and another staff explained his rights and completed the individuals¿ rights process documentation with individual #1 on 01/13/2024. |
01/13/2024
| Implemented |
6400.46(b) | Staff 2 does not have the credentials to be considered as a Fire Expert. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Staff responsible (former program specialist) had not renewed training nor informed the organization. Staff #2 was disciplined and subsequently is no longer with the organization. The site manager is in contact with a fire safety organization (Croker Fire Safety) to schedule training for the organization. |
02/15/2024
| Implemented |
6400.167(a)(4) | Staff 3 failed to give individual 1's his medication on 9/26/23, at 8AM at the prescribed time. | 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. | The medication was administered but the staff responsible failed to document the medication pass. Staff responsible was disciplined for the infraction and subsequently is no longer with the organization. |
01/15/2024
| Implemented |
6400.181(f) | It could not be determined if the assessment for individual 1 was provided to the team 30 days prior to the ISP meeting.
The assessment for individual 2 was not sent 30 days prior to ISP meeting assessment completed 8/5/23, ISP meeting conducted 8/11/23. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The staff responsible (former program specialist) was disciplined and is no longer with the organization. Upon her departure the organization learned many of the infractions found during this licensing inspection were intentional. The findings of this licensing inspection and subsequent findings regarding this former staff prompted a restructuring of the organization.
The program specialists will review the current annual assessment and related documents, composing a new assessment for Individual #1. |
04/03/2024
| Implemented |
6400.213(1)(i) | Photo of the individual 1 provided, was not dated.
Photo not dated for individual 2. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | The staff responsible (former program specialist) was disciplined and is no longer with the organization.
Individual #2 has relocated and is no longer with the organization. The house manager will take a new picture of individual #1, dating the photograph. |
01/25/2024
| Implemented |