| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.113(a) | Documentation that Individual 1 was trained in Fire Safety was not provided at time of inspection. | 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. | Documentation will remain on site and copy provided managment office . Program Specialist ensured individual 1 was trained in fire safety and upon her arrival to the home. documentation was reviewed in fire book and program book for individual 1 , individual was trained and document signed.on 1/22/2022 |
09/08/2022
| Implemented |
| 6400.141(a) | Individual 1 has not had a physical completed annually. The agency provided a Physical Form dated 05/21/2022 on a L.I.F.E. Group Medical Encounter Form which does not address review of medical history, Immunizations, TB screening, GYN exam, allergies, information pertinent in case of emergency, and special diet. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Program Specialist will ensure all documentation is on site orginal physical date completed on 4/14/22 which displayed all information was not located PS obtained on 5/21/2022 a copy from urgent care, which was not completed due to more information was needed to provided to urgent care, orginal physical was placed in medical book which was dated 4/14/22 |
05/24/2022
| Implemented |
| 6400.142(f) | Individual 1 did not have a dental hygiene plan in the record at the time of review. | 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. | Program Specialist will confirm that her dental hygiene plan located in individual 1 medical book an current dental needs are written in dental plane |
05/24/2022
| Implemented |
| 6400.151(c)(2) | TB screening for DSP 3 was not addressed on the physical form dated 07/29/2021. Staff did not complete a TB skin test before working with individuals. | 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. | Provider will ensure that all employees have appropirate physicals completed prior to working with our individuals. |
05/24/2022
| Implemented |
| 6400.181(a) | An annual assessment for Individual 1 was not completed timely, agency provided an assessment dated 02/04/2022 it could not be determined if assessment was completed annually. | 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. | Provider and program specialist will ensure that assesments are completed in a timley fashion and dated accorindingly. |
05/24/2022
| Implemented |
| 6400.181(e)(5) | Based on the assessment dated 02/04/2022, it states to see attached assessment checklist to determine if Individual 1 has the ability to Self-Administer medication. (Nothing provided) | The assessment must include the following information: The individual's ability to self-administer medications. | program specials will review individuals ability to self administer/identification of medication and document . program specialist will ask sc to update individual 1 plan to reflect changes base on observation and information provided. |
05/24/2022
| Implemented |
| 6400.181(e)(10) | A lifetime medical history was not provided for individual 1. | The assessment must include the following information: A lifetime medical history. | Program Specialist will confiorm that the life time medical of individual is on site as well as a copy maintained at the main offce for review. |
05/24/2022
| Implemented |
| 6400.31(b) | Individual rights for Individual1 were not provided. | The home shall educate, assist and provide the accommodation necessary for the individual to make choices and understand the individual's rights. | Program Specialist will conform that all consents and rights are present in medical books as well as program books. |
05/24/2022
| Implemented |
| 6400.169(d) | A record of training shall be kept showing DSP 1 has completed medication administration training. The Recert form was not signed by the trainer. (Staff DSP 1 is not permitted to administer medication until she is properly trained). Agency was informed during inspection and at the Closing Conference. | A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. | Program Specialist will conform that DSP 1one was trained and reach out to trainer to sign and verify training recertification date date , Program manager will ensure trainings are current. |
05/23/2022
| Implemented |
| 6400.169(d) | A record of training shall be kept showing DSP 3 has completed medication administration training. | A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. | Program Specialist/ program manager will confirm all personel files are completed for dsp3 and all trainings are properly reviewed for signatures dates, such as expirations and renewal dates |
05/25/2022
| Implemented |
| 6400.181(f) | Documentation that the program specialist provided the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting was not provided. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Program Special will provide assesment at least 30 days prior to individual plan meeting. . |
05/24/2022
| Implemented |