| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Poisonous materials are not being kept locked and made inaccessible to the individuals in the kitchen and the bathroom. | Poisonous materials shall be kept locked or made inaccessible to individuals. | WHO is responsible: Executive Director
WHAT will be corrected: Ensure that poisonous materials are kept locked in the kitchen and the bathroom cabinets.
WHEN AND HOW: On 2/20/2024. Created a general house checklist (that highlighted poisonous material) to be used weekly by the manager to monitor compliance with the regulation. Trained all staff on how to cross-check during shift changes that all poisonous materials are locked in the kitchen, bathroom, and any other storage place within the house. The cabinets are to be kept always locked during the shift. Keys are attached to the general house keys that the staff carries while on shift. Collated and filed training confirmation.
TARGET DATE: 3/21/2024
SPECIFIC COMPLETION DATE: 3/21/2024 |
06/27/2024
| Implemented |
| 6400.77(b) | No thermometer was in the first aid kit. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | WHO is responsible: Executive Director
WHAT will be corrected: Ensure that a thermometer is always included in the first aid kit.
WHEN AND HOW: 2/20/2024. Created a general house checklist (that highlighted thermometer) to be used weekly by the manager to monitor compliance with the regulation. On 3/21/24 all Staff were trained on how to cross-check that the thermometer is included in the first aid kit during shift changes. Collated and filed training confirmation.
TARGET DATE: 3/21/2024
SPECIFIC COMPLETION DATE: 3/21/2024 |
06/27/2024
| Implemented |
| 6400.141(c)(4) | Vision and hearing screenings for Individual #1 were not completed/documented on the physicals dated 03/01/2023 and 10/18/2023. That portion of the physical was left blank. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | 3.
WHO is responsible: Program Specialist
WHAT will be corrected: Ensure that Vision and Hearing Screenings sections on the Annual Physical Exam of individual #1 is reviewed and documented by the attending physician.
WHEN AND HOW: 3/5/2024. The program specialist scheduled an appointment with the PCP. 4/12/2024, PCP reviewed and documented the Vision and Hearing Screenings sections on the physical exam form. The program specialist reviewed the completed form for compliance with the regulation and filed it in the individual¿s medical book. All the staff have been trained on how to properly complete an Annual Physical Exam by ensuring that the attending physician completes all sections including Vision and Hearing Screenings.
TARGET DATE: 4/12/2024
SPECIFIC COMPLETION DATE: 4/12/2024 |
06/27/2024
| Implemented |
| 6400.141(c)(6) | On the medical form for Individual #2 dated 04/12/23 (TB) Tuberculin skin testing was not completed every 2 years last screening was given 04/29/2021 and read 05/01/2021. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | WHO is responsible: Program Specialist
WHAT will be corrected: Ensure that Tuberculin (TB) Skin Test for individual #2 is completed and documented on the annual physical form.
WHEN AND HOW: 3/5/2024. The program specialist scheduled an appointment with the PCP. 3/21/2024, all the staff have been trained on how to properly complete an Annual Physical Exam (PE) by ensuring that the attending physician completes all sections. 4/12/2024, PCP ordered QuantiFERON and documented on the physical exam form. The program specialist reviewed the completed form for compliance with the regulation and filed it in the individual¿s book. 4/17/2024, the program specialist retrieved the result of the TB test and filed it with the PE form.
TARGET DATE: 4/12/2024
SPECIFIC COMPLETION DATE: 4/12/2024 |
06/27/2024
| Implemented |
| 6400.141(c)(10) | On the physical dated 10/18/2023 for Individual #1 the communicable disease portion was left blank. | 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. | WHO is responsible: Program Specialist
WHAT will be corrected: Ensure that the Communicable Disease section on the Physical form for individual #1 is completed and documented by the physician.
WHEN AND HOW: 3/5/2024. The program specialist scheduled an appointment with the PCP. 3/21/2024, all the staff have been trained on how to properly complete an Annual Physical Exam (PE) by ensuring that the attending physician completes all sections including the Communicable Disease. 4/12/2024, PCP reviewed and documented Communicable Disease clearance on the physical exam form for individual #1. The program specialist reviewed the completed form for compliance with the regulation and filed it in the individual¿s book.
TARGET DATE: 4/12/2024
SPECIFIC COMPLETION DATE: 4/12/2024 |
06/27/2024
| Implemented |
| 6400.141(c)(10) | On the physical for Individual #2 dated 04/12/2023 the communicable disease portion was left blank. | 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. | WHO is responsible: Program Specialist
WHAT will be corrected: Ensure that the Communicable Disease section on the Physical form for individual #2 is completed and documented by the physician.
WHEN AND HOW: 3/5/2024. The program specialist scheduled an appointment with the PCP. 3/21/2024, all the staff have been trained on how to properly complete an Annual Physical Exam (PE) by ensuring that the attending physician completes all sections including the Communicable Disease. 4/12/2024, PCP reviewed and documented Communicable Disease clearance on the physical exam form for individual #2. The program specialist reviewed the completed form for compliance with the regulation and filed it in the individual¿s medical book.
TARGET DATE: 4/12/2024
SPECIFIC COMPLETION DATE: 4/12/2024 |
06/27/2024
| Implemented |
| 6400.144 | A mammogram was completed for individual #1 on 04/05/2023 and the recommendation from the doctor states a bilateral breast exam should be completed in 6 months. No appointment was made for the individual.
Dental Care for individual #1 is not being followed as prescribed by the doctor, the form dated 04/27/2023 states individual #1 needs oral surgery, no appointment has been scheduled for this surgery. The previous dental service form is not dated, and individual #1 has been in the agencies care since 08/01/2022. | 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.
| WHO is responsible: Program Specialist
WHAT will be corrected: Ensure that a follow-up appointment is made and review doctor¿s recommendation regarding mammogram and breast exam for individual #1
WHEN AND HOW: 3/5/2024. The program specialist reviewed the completed mammogram form, retrieved results for bilateral breast exam completed on 12/22/2023, scheduled a follow up appointment for 6/27/2024- mammogram at 10:00 AM and Ultrasound at 11:00 AM. 3/21/2024, all the staff have been trained on how to properly complete a mammogram appointment by ensuring that a follow up appointment is made before leaving the doctor¿ office, reviewing and reporting doctor¿s recommendations, and submitting the completed medical forms to the program specialist for more in-depth review. The program specialist reviewed the completed form for compliance with the regulation and filed it in the medical book.
TARGET DATE: 4/12/2024
SPECIFIC COMPLETION DATE: 4/12/2024 |
06/27/2024
| Implemented |
| 6400.181(a) | Individual #1 did not have an assessment completed annually. The assessment dated 09/29/2022 is a duplicate of the assessment dated 09/28/2023 with a few subtle changes.
Individual #2's assessment was not completed annually. The last assessment was completed 09/08/2022 and not again until 10/15/2023. The assessment dated 09/08/2022 is a duplicate of the assessment dated 10/15/2023. | 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. | WHO is responsible: Program Specialist
WHAT will be corrected: Ensure that a new Annual Assessment is completed for individual #1 that reflects the progress made over the year.
WHEN AND HOW: 3/5/2024, the program specialist reviewed all program notes, lifetime medical history, doctor notes, medical appointments, activity calendars, monitoring documents, and ISP. The program specialist conducted interviews with the individual, staff, and other team members. 4/10/2024, the program specialist completed a new Annual Assessment using the information gathered and making sure that it reflects the progress made by the individual over the year. The new assessment was shared and reviewed by the individual and members of the care team. A copy was filed in the individual¿s program book.
TARGET DATE: 4/10/2024
SPECIFIC COMPLETION DATE: 4/10/2024 |
06/27/2024
| Implemented |
| 6400.46(a) | Staff #1 - there is no general fire safety training in their record. | Program specialists and direct service workers shall be trained before working with individuals in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire, smoking safety procedures if individuals or staff persons smoke at the home, the use of fire extinguishers, smoke detectors and fire alarms, and notification of the local fire department as soon as possible after a fire is discovered. | WHO is responsible: Executive Director
WHAT will be corrected: Ensure that general Fire Safety Training is included in staff #1 record.
WHEN AND HOW: 2/20/2024, executive searched all the filing cabinets in the office and retrieved general fire safety trainings for staff #1 with completion dates of 8/2/2022 and 6/28/2023. The training documents were filed in the appropriate staff filed.
TARGET DATE: 2/20/2024
SPECIFIC COMPLETION DATE: 2/20/2024 |
06/27/2024
| Implemented |
| 6400.165(b) | PRN Medication Trueplus Glucose 4mg Tab for individual #2 is on the MAR but not present in the individuals medication box. | A prescription order shall be kept current. | WHO is responsible: Program Specialist
WHAT will be corrected: Ensure that TruePlus Glucose 4mg for individual #2 is on the MAR or be removed from the MAR if no longer needed.
WHEN AND HOW: 3/5/2024, the program specialist reviewed the MAR and contacted the pharmacy. The pharmacy has removed the TruePlus Glucose 4mg tab from the MAR. Pharmacy cited that they may remove a PRN from the MAR if it has not been used in over a year, which is the case of the TruePlus Glucose 4mg Tab.
TARGET DATE: 3/5/2024
SPECIFIC COMPLETION DATE: 3/5/2024 |
06/27/2024
| Implemented |
| 6400.213(1)(i) | 6400.213(1)(iii) Both individuals #1 & #2 records did not contain the language or means of communication spoken or understood by the individual. | 6400.213. Content of records. (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. | WHO is responsible: Program Specialist
WHAT will be corrected: Ensure that the language or means of communication spoken and understood by individual #1 & #2 is included in their Face Sheets.
WHEN AND HOW: 3/5/2024
TARGET DATE: 3/5/2024
SPECIFIC COMPLETION DATE: 3/5/2024 |
06/27/2024
| Implemented |