| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | In the basement, there were 3 outlets missing outlet covers. The exposed outlets create a safety hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The basement at this location is currently under construction. |
02/28/2022
| Implemented |
| 6400.68(c) | There is no documentation that coliform water test were completed. (Repeat violation 1/22/21) | A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept. | Water test completed on 12/20/21. |
03/20/2022
| Implemented |
| 6400.112(a) | There is no documentation that a fire drill occurred in November 2021. | An unannounced fire drill shall be held at least once a month. | All staff will be retrained on conducting and documenting fire drills, to include conducting fire drills monthly by 2.28.22. |
02/28/2022
| Implemented |
| 6400.112(h) | The 10/21/21, 9/4/21, and 3/24/21 fire drill records did not include documentation on if all the individuals evacuate to the designated meeting place outside the home during the drill as this section was left blank on the forms. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | All staff will be retrained on conducting and documenting fire drills, to include ensuring individuals evacuate to the designated meeting place and it is documented appropriately on the fire drill record by 2.28.22 |
02/28/2022
| Implemented |
| 6400.113(a) | There is no record of Fire Safety training for Individual #5. | 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. | Individual #5 will be trained on Fire Safety when the individual returns home from current hospitalization. |
03/15/2022
| Implemented |
| 6400.142(f) | There is no record of a Dental Hygiene plan for Individual #5. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | Agency to update Dental visit form by 3.13.22 to include a section for Dental Hygiene plan to be approved by the individual's dentist at each visit.
(Dentist for Individual #5 will be contacted for a dental hygiene plan -CH 3/18/22) |
03/30/2022
| Implemented |
| 6400.151(c)(2) | Staff #6's most recent tuberculin skin testing by Mantoux method with negative results was completed on 7/19/19. This exceeds the requirement. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | HR Generalist has been retrained by Human Resources to ensure she is aware of required regulations and has been requested to create tracking systems and audit all files to ensure full compliance. (Staff #6 will receive an updated Mantoux test -CH 3/18/22) |
02/28/2022
| Implemented |
| 6400.181(e)(10) | Lifetime Medical History was not included in Individual #5's assessment dated 6/3/2021. | The assessment must include the following information: A lifetime medical history. | Agency nurse will complete the Lifetime Medical History in conjunction with the Program Specialist during the individual's annual assessment. |
02/28/2022
| Implemented |
| 6400.181(e)(13)(ii) | Progress & growth in the communication area was not evaluated as this section was left blank on Individual #5's assessment dated 6/3/2021. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | Agency Program Specialists and Director will receive retraining on completing individual skill assessments to ensure all areas of progress and growth are being documented by 2.28.22 ( Assessment will be updated to include all required information -CH 3/18/22) |
02/28/2022
| Implemented |
| 6400.181(e)(13)(v) | Progress & growth in this area was not evaluated as this section was left blank on Individual #5's assessment dated 6/3/2021. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | Agency Program Specialists and Director will receive retraining on completing individual skill assessments to ensure all areas of progress and growth are being documented by 2.28.22 ( Assessment will be updated to include all required information -CH 3/18/22) |
02/28/2022
| Implemented |
| 6400.181(e)(13)(vii) | Progress & growth in this area was not evaluated as this section was left blank on Individual #5's assessment dated 5/1/2020. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| Agency Program Specialists and Director will receive retraining on completing individual skill assessments to ensure all areas of progress and growth are being documented by 2.28.22 ( Assessment will be updated to include all required information -CH 3/18/22) |
02/28/2022
| Implemented |
| 6400.34(a) | Individual #5 was informed of his rights on 1/10/2021. The rights haven't been updated to reflect the current Chapter 6400 regulations. The missing rights include: make choices/accept risks, refusal of activities, control schedule, voice concerns, telecommunications, choice of roommate, furnish/decorate bedroom and common areas, lock bedroom door, entry mechanism to lock/unlock the front door, access to food, make health care decisions, and rights may only be modified in accordance with § 6400.185 (relating to content of the individual plan) to the extent necessary to mitigate a significant health and safety risk to the individual or others. (Repeat Violation 1/19/21) | 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. | Individual rights will be updated to reflect current 6400 regulations. |
02/28/2022
| Implemented |
| 6400.165(g) | Individual #5 had a 3-month review on 9/29/21 and it did not document the reason for prescribing the medication, the need to continue the medication, and the necessary dosage. The 9/29/21 review was conduct via tele visit and there was no documentation that it was completed by a licensed physician as the form was not signed. The prior 3-month reviews did include documentation that they were completed by a licensed physician (Repeat Violation 1/19/22) | 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. | Agency nurse will receive all medical documentation and will review to ensure completion prior to filing in the individual's medical record. |
02/28/2022
| Implemented |
| 6400.166(a)(11) | : Individual #5's Medication Administration Record (MAR) did not have the diagnosis or purpose for the medication Lidocaine Pain relief. | 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. | All medication certified staff to be re-trained on the medication administration steps to include checking the pharmacy label on medications. Agency nurse will complete unannounced monthly medication audits to ensure all medications are labeled. |
02/28/2022
| Implemented |