| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | The dryer had lint build-up the size of a golf ball in the lint trap, surfaces shall be free of hazards. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Lint was immediately removed from the dryer lint trap. Staff check the dryer immediately after use to remove all lint. A staff meeting was held on 09/21/2020 to discuss surfaces shall be free of hazards such as floors, walls, ceilings, dryers, etc. In order to ensure long term compliance, in addition to re-training staff, we have also created an unannounced visit form effective November 19, 2020 to be completed bi-weekly
by a program specialist that consists of verifying that dryers/surfaces are free of hazards - specifically lint. |
09/17/2020
| Implemented |
| 6400.68(b) | The hot water in the bathroom temperature was observed at being 131.0 degrees, in the kitchen the temperature was 129.0 degrees. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The water temperature gauge on the hot water heater control module was re-positioned to ensure water would not exceed 120 degrees. The hot water temperature will be checked and is included in the unannounced visit form effective November 19, 2020 to be completed biweekly by an administrator |
09/18/2020
| Implemented |
| 6400.141(c)(9) | Individual 1 did not have an annual prostate exam in the record. | The physical examination shall include: A prostate examination for men 40 years of age or older. | Individual 1 prostate exam was completed on 11/11/2020. In order to ensure long term compliance, we have created and initiated a medical appointment tracking form on October 5, 2020 that will be completed quarterly by the program specialist and reviewed by the CEO |
11/11/2020
| Implemented |
| 6400.46(b) | Staff 1 Staff 2 and Staff 3 did not have annual fire safety completed. There was no current fire safety training for the 2020 calendar year found in the record.
Staff 2's fire safety training was last completed 7/8/19 while staff 1 and 3's fire safety were last completed 4/3/2019. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | All staff were trained by a fire safety expert in the training areas specified in the subsection (a) on 9/21/2020. In order to ensure long term compliance, we have developed a bi-annual compliance review form effective 10/5/2020 in which staff trainings are reviewed and monitored by the program specialist. |
09/21/2020
| Implemented |
| 6400.165(c) | Individual 1 medication record is not being kept correctly, the individual prescription medication (Vitamin D 1000mg) is administered at 9:00pm and the MAR states it should be administered at 9:00am. The staff is signing the MAR and not administering as prescribed. | A prescription medication shall be administered as prescribed. | All prescription medications shall be administered as prescribed. Staff were retrained on the 5 rights of medication administration on 9/25/20. In order to ensure long term compliance in addition to re-training staff, we have also created an unannounced visit form effective 11/19/2020 to be completed biweekly by our program specialist that consists of verifying that all medications are administered as prescribed. |
09/25/2020
| Implemented |
| 6400.166(a)(7) | Individual 1 medication (OMEGA 3), is not being given as prescribed (labeled incorrectly). The MAR states give one capsule twice a day and the medication pack states take two capsules at morning. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | All prescription medications shall be administered as prescribed. Staff were retrained on the 5 rights of medication administration on 9/25/20. In order to ensure long term compliance in addition to re-training staff, we have also created an unannounced visit form effective 11/19/2020 to be completed biweekly by our program specialist that consists of verifying that all medications are administered as prescribed. |
12/04/2020
| Implemented |
| 6400.166(a)(10) | Individual 1 medication record is not being kept correctly, the individual prescription medication (Vitamin D 1000mg) is administered at 9:00pm and the MAR states it should be administered at 9:00am. The staff is signing the MAR and not administering as prescribed. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | All prescription medications shall be administered as prescribed. Staff were retrained on the 5 rights of medication administration on 9/25/2020. In order to ensure long term compliance, in addition to re-training staff, we have created an unannounced visit form effective 11/19/2020 to be completed biweekly by our administrator that consists of verifying all medications are administered as prescribed and on time. |
09/25/2020
| Implemented |
| 6400.181(f) | Verification that a copy of the assessment was sent to the individual plan team at least 30 days prior to the team meeting on 10/25/2019 was not located in record for individual 1. | 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 program specialist will provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. The assessment was sent via USPS mail to the individual team members on 9/15/2019 which was at least 30 days prior. Therefore, MaryJo Home Care only had the signed and dated letter in the file which was not proof that it was received by the team members. We re-sent the assessment via email to the plan team members on 12/2/2020. In order to ensure compliance, we will ensure that the assessments are sent out via email; the emails will be printed out and placed in the individual file attached to the assessment. The program specialist will check individual program books quarterly to ensure all applicable documents are included as required |
12/02/2020
| Implemented |