| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.43(b)(1) | At the time of the inspection the physicals completed for Staff #2 and Staff #4 on 5/18/24 were identical. The same document was provided for both Staff #2 and Staff #4. The only difference was the staff's names were handwritten in the corner of the document. Policy requires staff to have physicals completed at hire and biannually thereafter. There is no documentation verifying that the staff had physicals completed. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | -Both Staff #2 and Staff #4 will be scheduled for a new physical examination immediately.
-The document will be signed by the physician conducting the exams and attached to each staff member¿s file.
-The old document previously used for both staff members will not be used, and a new document meeting all requirements will be used moving forward
-The staff members will not be assigned direct care responsibilities until the physicals are completed and proper documentation is filed.
-Each staff member's physical examination documentation will be separately filed and clearly labeled to prevent future confusion.
-We will review all staff records to ensure all other physicals are properly documented and distinguishable. |
09/27/2024
| Implemented |
| 6400.64(a) | At the time of the inspection, the ceiling vents in both bathrooms were covered in thick dust/debris. | Clean and sanitary conditions shall be maintained in the home. | -The ceiling vents in both bathrooms will be thoroughly cleaned within 48 hours to remove all dust and debris.
-A professional cleaning service will be contracted to ensure that all vents are cleaned properly and in compliance with health and safety standards.
-After the cleaning, the Maintenance Supervisor will inspect the vents to verify that they are free from dust and debris.
-Photos of the cleaned vents will be taken and kept on file as proof of corrective action. |
09/25/2024
| Implemented |
| 6400.82(f) | At the time of the inspection on 9/17/24, there were no paper towels or cloth towels available in the either of the bathrooms in the home. | 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. | -Paper towels will be immediately restocked in both bathrooms within 24 hours to ensure proper hand hygiene for staff and residents.
-A supply of cloth towels will be made available for those who prefer them, with a designated bin for used towels.
-A checklist will be created for staff to ensure that paper towels and/or cloth towels are checked and restocked as needed at the beginning of each shift. |
09/27/2024
| Implemented |
| 6400.101 | At the time of the inspection on 9/17/24, the back door of the home was inoperable. It was unable to be opened. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| -A certified technician will be called within 24 hours to assess and repair the back door to ensure it is fully operable.
-The back door will be repaired within 72 hours or replaced if necessary to meet safety and accessibility standards.
-Once repaired, the Maintenance Supervisor will inspect the door to verify that it is functioning properly and can be easily opened.
Photos and documentation of the repair will be kept on file as proof of corrective action. |
09/25/2024
| Implemented |
| 6400.112(a) | Individual #1 moved into the home on 4/29/24 and did not participate in a fire drill until 5/15/24. | An unannounced fire drill shall be held at least once a month. | -Going forward, any new individual moving into the home will participate in a fire drill on the same day they move in. This will ensure immediate familiarization with emergency procedures and compliance with fire safety protocols.
-A review of the Fire Drill Log will be conducted to confirm that Individual #1 participation is properly documented. |
09/25/2024
| Implemented |
| 6400.112(d) | The fire drill conducted on 7/15/24 recorded the evacuation time as 2 minutes and 45 seconds. This is over the allowable time of 2.5 minutes. No repeat drill was conducted. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | -A repeat fire drill will be scheduled and conducted within the next week to ensure that all individuals can evacuate within the required time frame of 2.5 minutes.
-The results of this drill will be documented and reviewed for compliance.
-Monthly fire drills will be scheduled to ensure consistent practice and improvement in evacuation times. Each drill will be evaluated to monitor compliance with the 2.5-minute evacuation requirement.
-The House Manager will oversee the scheduling and execution of these drills, ensuring documentation is completed.
Staff will review evacuation procedures and strategies to improve response times during fire drills.
Emphasis will be placed on ensuring that all staff are familiar with their roles and responsibilities during an evacuation. |
09/27/2024
| Implemented |
| 6400.151(a) | At the time of the inspection, staff #2 and #4 did not have any valid physical exam in their record. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | -Staff #2 and Staff #4 will be scheduled for physical examinations immediately to ensure compliance with the policy.
-Verification of these examinations will be obtained and documented in their personnel files upon completion.
The records for Staff #2 and Staff #4 will be reviewed to ensure all necessary documentation is complete and up to date. |
09/25/2024
| Implemented |
| 6400.181(a) | The initial assessment dated 4/29/24 is incomplete and does not include all required information. | 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 missing components of the initial assessment, including the assessment of adaptive behavior and level of skills, will be completed within the next 7 days by the program specialist and placed in the individual's file.
-The documentation process for initial assessments will be reviewed to ensure all required information is included.
-A checklist will be developed to ensure that future assessments meet all regulatory requirements and are fully completed within 6 months prior to admission to the residential home. |
09/25/2024
| Implemented |
| 6400.52(c)(6) | Individual #1 has a seizure disorder. There is a general seizure protocol in place. Staff #2 and #3 were not trained in this protocol as part of their ongoing training on the individual's needs. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | -All staff, including Staff #2 and Staff #3, will receive immediate training on Individual #1's seizure protocol and the implementation of their plan.
-The training will be conducted by a qualified healthcare professional within the next 7 days, and attendance will be documented for each staff member in their personnel files. |
09/27/2024
| Implemented |
| 6400.166(a)(2) | The April 2024 through September 2024 medication records do not include the name of the prescriber for the following medications: Nifedipine ER, Metoprolol Succinate ER, Divalproex NA DR, Keppra, Meclizine HCL, Atorvastatin Calcium, Aspirin, and Acetaminophen. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | -The medication records will be immediately updated to include the name of the prescriber for each of the listed medications.
-This will be completed by reviewing prescriptions and medical records to ensure accurate and up-to-date documentation for each individual.
-The healthcare provider or pharmacy will be contacted to verify and confirm the prescriber's name for each medication, ensuring the correct information is entered into the medication records. |
09/25/2024
| Implemented |
| 6400.166(a)(11) | The April 2024 through September 2024 medication record did not include a diagnosis or purpose for the following medications: Divalproex NA DR 500mg and Aspirin 81mg. | 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. | -The medication records will be immediately updated to include the diagnosis or purpose for the medications Divalproex NA DR 500mg and Aspirin 81mg.
-This will be done by reviewing the individual's medical records and prescriptions to ensure the correct information is documented for each medication.
-The healthcare provider or pharmacy will be contacted, if necessary, to confirm the diagnosis or purpose for each medication and ensure that the correct details are entered into the records. |
09/27/2024
| Implemented |
| 6400.213(1)(i) | The record did not contain the following demographic information in the record: hair color/eye color/identifying marks, primary language, religious preference, next of kin, or current, dated photo. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. (ii) The race, height, weight, color of hair, color of eyes and identifying marks. (iii) The language or means of communication spoken or understood by the individual and the primary language used in the individual's natural home, if other than English. (iv) The religious affiliation. (v) The next of kin. (vi) A current, dated photograph. | -The individuals record will be updated immediately to include all missing demographic information: hair color, eye color, identifying marks, primary language, religious preference, next of kin, and a current, dated photo.
-This will involve gathering the necessary information from the individual, family members, or previous records.
A current, dated photograph of the individual will be taken and added to the record within the next 7 days. |
09/25/2024
| Implemented |