| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | There is no indication the provider has an up-to-date financial record for individual 2 that determines funds received by or deposited. Individual 2 combined SSI check was deposited on 5/17/2023 for $6252.00 as provider indicated checks are held in their possession until they are able to cash them. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | There was an error with the Social Security Office and the assigned rep payee causing the check to be drafted in the Agency's name instead of the individual and rep payee name. it was reported to Social Security, and they corrected the name and reissued a check in the individual's name. Keystone CFO opened the rep payee bank account and deposited the SSI check into the individual's rep payee account on 5/25/23. Banking statements will be kept ensuring up-to-date financials records are maintained. |
06/25/2023
| Implemented |
| 6400.68(a) | The home did not have hot running water, the water was measured at 90.2*F and measured again with a cooler reading of 87.7*F. | A home shall have hot and cold running water under pressure. | Keystone staff are required to check the in home water temperatures regularly; it is documented on our monthly fire drill forms and submitted for review. Prior to this day, all temperatures were within regulatory limits. On the morning of inspection, our maintenance staff went to each home testing the water temperature. In speaking with him, he misinterpreted the regulatory water temperature range and lowered the temperature from the water heater causing the water to measure below the range. The maintenance staff was retrained 6/26/2023 on the outlined water range, the hot water heater dial was readjusted the day of inspection (6/23/2023) so the water temperature was sufficiently hot; the water temperature was tested for 7 days straight and it read appropriately |
06/26/2023
| Implemented |
| 6400.144 | Medication (SF-500 PLUS 1.1% CREAM) is not being administered as prescribed, the staff is signing the MAR as completed but the medication is not present at the home for individual 2
Individual 5's Hospitalization on 10/12/2022 as it is indicated on the fire drill, she was not present, the provider did not provide documentation of the hospitalization. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| The medication (SF-500 PLUS 1.1% CREAM) for individual 2 was depleted and re-fill was requested.
Staff has received corrective action and will receive retraining for medication administration. Keystone will review internal protocols to ensure that services are being rendered in the most safe manner.
Individual 5 has remained hospitalized since 10/12/2022. Keystone has not received documentation, as Individual 5 has not returned to Keystone¿s care. A HCSIS report was generated following Individual 5¿s admission to the hospital. Keystone will print a copy of the HCSIS report to place in Individual 5¿s program book |
06/30/2023
| Implemented |
| 6400.24 | Controlled substance medication was not double locked per federal guidelines. | The home shall comply with applicable Federal and State statutes and regulations and local ordinances. | . All controlled substances will be kept in a locked med box (single lock) and inside a locked closet (double lock). These medications have been relocated to the second floor where it can be double locked. This occurred on 6/24/2023. |
06/24/2023
| Implemented |
| 6400.32(r) | Individual 2 individual rights do not indicate the right to lock individual bedroom door. | An individual has the right to lock the individual's bedroom door. | Individual #2 did have a current, signed individual rights forms on the chart, but Keystone was not aware that the Individual Rights section had been updated and that our forms did not have all the outlined rights listed in 6400.32a. Our in-house Individual Rights forms were updated on 6/27/23 and was reviewed with and signed by individual #2 on 7/1/2023. Additionally, the new rights form was reviewed and signed with all of the individuals and placed in their charts |
09/04/2023
| Implemented |
| 6400.165(b) | The PRN medication (TRIAMCINOLONE 0.1% CREAM) not in med box but listed on the MAR. for individual 2 | A prescription order shall be kept current. | The medication (Triamcinolone 0.1% CREAM) for individual 2 was depleted and re-fill was requested. |
06/30/2023
| Implemented |