| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | On 7/3/24 a coffee maker in the right cabinet above the sink that was on its side with a used coffee filter and coffee grounds still in the machine | Clean and sanitary conditions shall be maintained in the home. | The coffee maker was immediately cleaned and sanitized.
The surrounding area, including the cabinet, was cleaned to ensure no residual contamination |
09/02/2024
| Implemented |
| 6400.72(a) | On 7/3/24 Individual #1's bedroom windows were operable and did not have screens. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | The windows in Individual #1¿s bedroom were immediately closed to prevent any further risk until screens could be installed.
A maintenance request was submitted for the immediate installation of screens on all operable windows.
On 8/1/24 added screen since window opens from both sides |
08/01/2024
| Implemented |
| 6400.101 | On 7/3/24 there was a wooden 2x4 piece of wood that was secured across the basement door with brackets that would obstruct exit from the basement in case of emergency. | Stairways, halls, doorways, passageways and exits from rooms and from the building shall be unobstructed.
| -The wooden 2x4 was immediately removed from the basement door.
-Staff were instructed to check all exits in the building to ensure they are unobstructed. |
09/02/2024
| Implemented |
| 6400.141(c)(1) | Individual #1's most recent physical examination, dated 06/25/24, did not address: a review of previous medical history. | The physical examination shall include: A review of previous medical history. | -Contacted the healthcare provider to request a comprehensive review of Individual #1¿s
previous medical history.
-Ensured that the missing information was added to Individual #1's medical record. |
09/02/2024
| Implemented |
| 6400.141(c)(3) | Individual #1's most recent physical examination, dated 06/25/24, did not address: immunizations | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | -The healthcare provider was contacted immediately, and an updated physical examination, including a complete record of Individual #1¿s immunizations, was completed on 8-5-24. This updated examination has been added to Individual #1's medical records. |
08/05/2024
| Implemented |
| 6400.141(c)(6) | Individual #1's most recent physical examination, dated 06/25/24, did not address: Tuberculin evaluation | 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. | -Scheduled an immediate follow-up appointment for Tuberculin skin testing on 7/8/2024. |
09/02/2024
| Implemented |
| 6400.141(c)(13) | Individual #1's most recent physical examination, dated 06/25/24, did not address: allergies or contraindicated medication. | The physical examination shall include: Allergies or contraindicated medications. | -Contacted the healthcare provider to obtain and document the missing information.
- Updated Individual #1's medical records to reflect allergies and contraindications. |
09/02/2024
| Implemented |
| 6400.143(a) | Individual #1 refused medical appointment on 04/30/24 and 06/25/24, and a dental appointment on 05/15/24. There is no documentation of continued education on the importance of these appointments. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | -Documented the refusals and educated Individual #1 on the importance of attending
medical and dental appointments.
-Rescheduled the missed appointments. |
09/02/2024
| Implemented |
| 6400.214(b) | The following information for individual #1's record was not available in the residential home for review at the time of the investigation on 07/03/24: current dated physical, dental appointments, current assessment, ISP documents | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| -Retrieved and filed all missing documents in Individual #1's record.
- Conducted a review to ensure all other records were up to date and complete. |
09/02/2024
| Implemented |
| 6400.18(f) | On 07/03/24 Direct Service Worker #2, who is a named target of abuse allegations, was working in another home directly with individuals and was not suspended as required. | The home shall take immediate action to protect the health, safety and well-being of the individual following the initial knowledge or notice of an incident, alleged incident or suspected incident. | -Direct Service Worker #2 was immediately suspended pending the outcome of the
investigation.
-The incident was reported to relevant authorities as per protocol. |
09/02/2024
| Implemented |
| 6400.163(h) | On 7/3/24 there was a box containing Albuterol Sulfate Inhalation Aerosol HFA 108 located in the medicine cupboard of the home that was prescribed for an individual who no longer resides in the home. Nayzilam 5mg/0.1ml solution with instructions "Use 1 spray (2.5mg) via atomizer per nostril for seizure >5 minutes. If seizure does not stop after 3 additional minutes, call 911." had an atomizer that expired January 30th, 2024, which was present in the home. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | -In accordance with 6400.163(h), the expired Nayzilam atomizer was immediately removed and properly disposed of, and the Albuterol Sulfate Inhalation Aerosol was also removed and disposed of according to state and federal regulations.
- The medication cupboard was then thoroughly inspected to ensure no other expired or discontinued medications were present. |
09/02/2024
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medications to treat the symptoms of a diagnosed psychiatric illness. Individual #1 had a psychiatric medication review on 08/01/23, and then again on 12/11/23. This exceeds the at least every 3-month requirement. Individual #1 had a psychiatric medication review on 12/11/23, and then again on 04/08/24. This exceeds the at least every 3-month requirement. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | -An immediate psychiatric medication review was scheduled and completed on 12/11/23. Moving forward, a strict schedule will be established to ensure that Individual #1's psychiatric medication reviews are conducted every three months without exception |
09/02/2024
| Implemented |
| 6400.166(a)(11) | Individual #1's July 2024 Medication Administration Record (MAR did not contain a diagnosis or purpose for the following medication: Venlafaxine ER 150 MG Cap with instructions "Take one capsule by mouth daily." | 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 MAR has been immediately updated to include the correct diagnosis and purpose for this medication. |
09/02/2024
| Implemented |
| 6400.166(a)(15) | Individual #1 was prescribed Benztropine Mes 1 MG Tablet with instructions "Take one tablet by mouth every 6 hours as needed for side effects, Max 2 doses per day;" however, no instructions for when to administer medication were provided. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Special precautions, if applicable. | - The prescribing physician was contacted immediately to clarify the specific instructions for administering the medication.
- The updated instructions, detailing when to administer the medication, have been added to the Medication Administration Record (MAR) and communicated to all relevant staff. |
09/02/2024
| Implemented |
| 6400.166(d) | On 7/3/24, Individual #1's July 2024 Medication Administration Record (MAR) indicated, by staff's initials, that Individual #1 was administered Vitamin B12 250 mg at 8 AM on 07/01/24; however, this medication had previously been discontinued in December of 2023. | The directions of the prescriber shall be followed. | -Immediate action was taken to review the Medication Administration Record (MAR) and ensure no further doses were given.
The staff member responsible for the error was retrained on proper MAR review and medication administration procedures.
-The discontinued medication was immediately removed from the medication storage area to prevent future errors. |
09/02/2024
| Implemented |