| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.113(a) | Individual 1's fire safety training was completed more than a year apart (6/28/23 to 8/6/24). | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually 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 and smoking safety procedures if individuals smoke at the home. | The individual was already trained on 8/6/2024. However, the program specialist shall ensure all individuals within Divine support services are trained in fire safety training annually moving forward to ensure compliance. See attachment #2 |
09/10/2024
| Implemented |
| 6400.141(c)(14) | Individual 1's most recent physical form does not include information pertinent to diagnoses in case of emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Individual #1 went for consultation to the doctor on 9/13/2024 and the physical examination included medical information pertinent to diagnosis and treatment in case of an emergency. See attachment#3. |
09/13/2024
| Implemented |
| 6400.144 | For individual 1- Prostate exam is marked as "deferred" since (at least) 2020 on the physical forms. However, there is no additional documentation or explanation that explains the rationale for the deferment. Documentation of a cardiology visit from 2023 indicated that they were meant to have a follow up appointment in "approximately one year" documentation of the 2024 visit was not found in the record. Also, Individual 1's PRN Medication Mucinex DM Tab 30-600 ER2 was listed on MAR but was not available in the home. Their Medication Ketoconazonle Cream 2% / for Nizoral (Apply to bottom of foot daily, avoid between the toes. Apply for 4 weeks). Filled 8/12/2024. Was available in med box, but not listed or handwritten on MAR. | 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.
| Individual 1 prostate exam marked as ¿deferred¿ appointment was completed on 9/13/2024. The cardiology appointment for annual was completed on 8/28/24. Individual 1's PRN Medication Mucinex DM Tab 30-600 ER2 was listed on MAR but was not available in the home, was discontinued by the doctor on 9/3/2024. The Medication Ketoconazonle Cream 2% / for Nizoral (Apply to bottom of foot daily, avoid between the toes. Apply for 4 weeks). Filled 8/12/2024 documentation was corrected on the MAR on 9/1/2024. See attachments #4. |
09/03/2024
| Implemented |
| 6400.32(r) | The current Rights form signed by individual 1 does not include the right to having a lock on their bedroom door. | An individual has the right to lock the individual's bedroom door. | The Individual rights policy was updated on 9/10/2024 to ensure it includes individuals having the right to lock their bedroom doors. attachment #1 |
09/10/2024
| Implemented |
| 6400.34(a) | The rights form for individual 1 was signed more than a year apart (10/8/22 to 1/5/24). | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | The individual rights have already been completed on 1/5/2024. However, in the future, the program specialist shall ensure all individuals¿ rights are updated annually for compliance. see attachment#1 |
09/10/2024
| Implemented |