| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(2) | The financial log for individual #1 dated 7/12/2022 had a starting balance of $101.04. Then $1.58 was spent and the new balance should read $99.46 but staff recorded the new balance as $98.46. This error was not caught for the month of July and the incorrect balance transferred to the August 2022 ledger and all of august was also off $1.00 for the entire month. | (2) Disbursements made to or for the individual.
| 9/21/2022: The financial audits for individual #1 were immediately fixed and recalculated through 9/21/2022. The money in the home was counted and added to the final balance through September.
- Attachment # 10a-c
10/20/2022: All staff will be trained on the plan of correction at their all staff meeting on 10/20/2022. This roster will be sent as evidence on 10/21/22. |
09/21/2022
| Implemented |
| 6400.68(b) | Water temperature at the kitchen sink was 123.8 degrees Fahrenheit. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | 9/21/2022: The water heater temperature was immediately lowered by the CEO. The water temperature was checked twice at two separate times thereafter and did not exceed 120°f. All other home temperatures were monitored for safety and were in compliance.
- Attachment # 9
10/20/2022: All staff will be trained on the plan of correction at their all staff meeting on 10/20/2022. This roster will be sent as evidence on 10/21/22. |
09/21/2022
| Implemented |
| 6400.211(b)(1) | Individual #1's record did not contain the address of the designated person 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.
| 9/21/2022: Immediately upon discovery, the program specialist added the address of the designated person to be contacted in case of an emergency.
Attachment #13
9/23/22 - Demographic and emergency information for all individuals in the care of Apex Healthcare Services, LLC was reviewed for compliance. |
09/23/2022
| Implemented |
| 6400.211(b)(3) | Individual #1's record did not contain the address of the person able to give consent or emergency medical treatment, or the addresses of the alternate contacts. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.
| 9/21/2022: Immediately upon discovery, the program specialist added the address of the person able to give consent or emergency medical treatment and the addresses of the alternate contacts.
Attachment #13
9/23/22 - Demographic and emergency information for all individuals in the care of Apex Healthcare Services, LLC was reviewed for compliance. |
09/23/2022
| Implemented |
| 6400.214(b) | Individual # 1's ISP last updated 01/05/21 was at the home during the walk through on 09/21/22. | The most current copies of record information required in § 6400.213(2)(14) shall be kept at the residential home. | 9/22/2022: The updated ISP for individual 1 was printed and placed in the individual's general binder. The old ISP was placed in the Archived Records by the Program Specialist and Director of Community Homes.- Attachment #14
9/23/22 - All binders for individual's in the care of Apex Healthcare Services were reviewed to ensure the most recent ISP was included.
10/20/2022: All staff will be trained on the plan of correction at their all staff meeting. This roster will be sent as evidence on 10/21/22. |
09/22/2022
| Implemented |
| 6400.32(c) | Individual #1's rights statement signed 11/16/22 does not include the right to be free from exploitation and abandonment. | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | 9/22/2022 - The Program Specialist created a revised Rights Statement that includes the right to be free from exploitation and abandonment.
Attachment #8a
9/28/2022 - The rights statement was reviewed with individual #1 as well as his guardian by the Program Specialist. The individual signed the statement on the same day.
Attachment #8a-e
9/28/2022-10/6/2022 -The new Rights Statement was reviewed with all individuals receiving services through Apex Healthcare Services, LLC Community Homes and copies have been sent to their guardians.
10/20/2022: All staff will be trained on the plan of correction at their all staff meeting. This roster will be sent as evidence on 10/21/22. |
10/06/2022
| Implemented |
| 6400.32(e) | Individual #1's rights statement signed 11/16/22 does not include the right to make choices and accept risks. | An individual has the right to make choices and accept risks. | 9/22/2022 ¿ The Program Specialist created a revised Rights Statement that includes the right to make choices and accept risk
Attachment #8a
9/28/2022 - The rights statement was reviewed with individual #1 as well as his guardian by the Program Specialist. The individual signed the statement on the same day.
Attachment #8a-e
9/28/2022-10/6/2022 The new Rights Statement was reviewed with all individuals receiving services through Apex Healthcare Services, LLC Community Homes and copies have been sent to their guardians.
10/20/2022: All staff will be trained on the plan of correction at their all staff meeting on 10/20/2022. |
09/28/2022
| Implemented |
| 6400.32(p) | Individual # 1's rights statement signed on 11/16/22 does not include the right to choose persons with whom to share a bedroom. | An individual has the right to choose persons with whom to share a bedroom. | 9/22/2022 - The Program Specialist created a revised Rights Statement that includes the right to choose persons with whom to share a bedroom.
Attachment #8a
9/28/2022 - The rights statement was reviewed with individual #1 as well as his guardian by the Program Specialist. The individual signed the statement on the same day.
Attachment #8a-e
9/28/2022 - The new Rights Statement was reviewed with all individuals receiving services through Apex Healthcare Services, LLC Community Homes and copies have been sent to their guardians.
10/20/2022: All staff will be trained on the plan of correction at their all staff meeting. This roster will be sent as evidence on 10/21/22. |
09/28/2022
| Implemented |
| 6400.32(q) | Individual # 1's rights statement signed on 11/16/22 does not include the right to furnish and decorate their bedroom. | An individual has the right to furnish and decorate the individual's bedroom and the common areas of the home in accordance with § 6400.33 (relating to negotiation of choices). | 9/22/2022 - The Program Specialist created a revised Rights Statement that includes the right to furnish and decorate their bedroom.
Attachment #8a
9/28/2022 - The rights statement was reviewed with individual #1 as well as his guardian by the Program Specialist. The individual signed the statement on the same day.
Attachment #8a-e
9/23/2022 - The new Rights Statement was reviewed with all individuals receiving services through Apex Healthcare Services, LLC Community Homes and copies have been sent to their guardians.
10/20/2022: All staff will be trained on the plan of correction at their all staff meeting. This roster will be sent as evidence on 10/21/22. |
09/28/2022
| Implemented |
| 6400.32(r) | Individual # 1's rights statement signed on 11/16/22 does not include the right to lock their bedroom door. | An individual has the right to lock the individual's bedroom door. | 9/22/2022 -The Program Specialist created a revised Rights Statement that includes the right to lock their bedroom door.
Attachment #8a
9/28/2022 - The rights statement was reviewed with individual #1 as well as his guardian by the Program Specialist. The individual signed the statement on the same day.
Attachment #8a-e
9/23/2022 - The new Rights Statement was reviewed with all individuals receiving services through Apex Healthcare Services, LLC Community Homes and copies have been sent to their guardians.
10/20/2022: All staff will be trained on the plan of correction at their all staff meeting. This roster will be sent as evidence on 10/21/22. |
09/28/2022
| Implemented |
| 6400.32(s) | Individual # 1's rights statement signed on 11/16/22 does not include the right to have a key or access to lock and unlock the entrance door of the home. | An individual has the right to have a key, access card, keypad code or other entry mechanism to lock and unlock an entrance door of the home. | 9/22/2022 -The Program Specialist created a revised Rights Statement that includes the right to have a key or access to lock and unlock the entrance door of the home.
Attachment #8a
9/28/2022 - The rights statement was reviewed with individual #1 as well as his guardian by the Program Specialist. The individual signed the statement on the same day.
Attachment #8a-e
9/23/2022 -The new Rights Statement was reviewed with all individuals receiving services through Apex Healthcare Services, LLC Community Homes and copies have been sent to their guardians.
10/20/2022: All staff will be trained on the plan of correction at their all staff meeting on10/20/2022.This roster will be sent as evidence on 10/21/22. |
09/28/2022
| Implemented |
| 6400.32(t) | Individual # 1's rights statement signed on 11/16/22 does not include the right to access food at any time. | An individual has the right to access food at any time. | 9/22/2022 - The Program Specialist created a revised Rights Statement that includes the right to access food at any time.
Attachment #8a
9/28/2022 - The rights statement was reviewed with individual #1 as well as his guardian by the Program Specialist. The individual signed the statement on the same day.
Attachment #8a-e
9/23/2022 - The new Rights Statement was reviewed with all individuals receiving services through Apex Healthcare Services, LLC Community Homes and copies have been sent to their guardians.
10/20/2022: All staff will be trained on the plan of correction at their all staff meeting on10/20/2022.This roster will be sent as evidence on 10/21/22. |
09/28/2022
| Implemented |
| 6400.166(a)(11) | Individual #1's Medication Administration Record does not indicate the diagnosis or purpose of any of the prescribed medications. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | 9/22/2022: The Program Specialist has added the purpose of the medication for each medication on the MAR.
Attachment #11a-b
9/22/2022: All individual's MARs were reviewed by the Program Specialist and Director of Community Homes to ensure that all components of the MAR were present.
10/20/2022: All staff will be trained on the plan of correction at their all staff meeting on10/20/2022.This roster will be sent as evidence on 10/21/22. |
09/22/2022
| Implemented |
| 6400.194(d) | Individual #1's record did not contain a record of the human rights team meeting at the time of inspection. | A record of the human rights team meetings shall be kept. | 9/27/2022: The minutes of the meeting were obtained immediately upon discovery by the Director of Community Homes and placed in individual #1s binder in the home.
- Attachment #12a.1 - 12a.3, 12b.1 - 12b.3
10/20/2022: All staff will be trained on the plan of correction at their all staff meeting on 10/20/2022.This roster will be sent as evidence on 10/21/22. |
09/27/2022
| Implemented |