| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(2) | Individual #1's ledgers just state check but does not track amount coming in or out being spent via checkboard. The geift cards are being tracked by the number of giftcards and not by the amount spent on the cards. | (2) Disbursements made to or for the individual.
| (What does the ISP say about the ability to handle finances)
The individual #1 has received gift card and checks from family and friends. The intention is to keep detailed records of the amount of funds available to the resident. The policy has been updated to reflect the need for the staff person to maintain the gift card receipt with the gift card. In the absence of the receipt the staff person will call the number on the back of the gift card get a new balance and document it on a slip of paper attached to the gift card with the date and staff initials.
A check in the company¿s possession must be recorded on the ledger and rewritten with each count. |
01/31/2024
| Implemented |
| 6400.81(k)(6) | Individual #2 did not have a mirror at the time of the inspection in their room. | In bedrooms, each individual shall have the following: A mirror. | The individual did not have a mirror in his room as required in the 6400.81(k)(6) regulation. A mirror was purchased on 1/25/2024 see attached receipt. The mirrors were installed by maintenance on 1/29/2024, see maintenance log.
The staff have been educated on the regulation, see training record attached. |
01/31/2024
| Implemented |
| 6400.104 | The fire letter send on 1/16/2024 included all the homes and individuals as a whole and is not specific to the home in question. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Program Specialist faxed a letter and house layouts of all 7 homes in our program to the local fire department on 1/16/24. Program Specialist misunderstood the regulations and sent one letter addressing the homes and residents needs of all 7 homes along with 7 individual house layouts in one fax. Program Specialist should have sent 7 individual letters describing each home and the resident(s) that live there so that the fire department had individualized information regarding the home and the residents that live there. This regulation is important because a more individualized plan for the fire department will be easier for them to understand in the event of an emergency rather than looking through information for multiple homes at once. On 1/31/24, Program Specialist resubmitted this information to the Fire department in the form of an email. Each of the 7 homes were identified and described in the letter as well as the number of residents and what their needs would be for safely evacuating their home. Moving forward, this letter will be updated annually or as needed so that the fire department has the most current information. |
01/30/2024
| Implemented |
| 6400.163(a) | Individual #1's medication Sumatripton Nasal spray USP 20mg did not have a label. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | Rachel is prescribed Sumatriptan Nasal Spray USP 20mg (PRN). These are individually wrapped nose sprays. The pharmacy sent them to us loose, without a label as they count them out of a larger supply box. We failed to notice that they were not individually labeled, and did not send them back to be re labeled. This regulation is important because we need to know that the medication we administer is correct, and without a label, it is not possible to be certain about its accuracy. We have requested the pharmacy to relabel the medications, which was provided to us on 2/1/24. |
01/30/2024
| Implemented |
| 6400.186 | Individual #1 ISP does not reference the locked fridge or cabinets in the house. Staff state that if she asks for something they provider access. There is a food restriction for the housemate. | The home shall implement the individual plan, including revisions. | The individuals housemate has a restrictive plan for food that requires the refrigerator to be locked for her safety. R is aware of this and is understanding of this measure for her house mates safety. has been in agreement with the current policy of keeping the refrigerator locked and asking staff for help getting food when she wants it. We failed to document this arrangement in her ISP. This regulation is important because a plan cannot be properly implemented if it is not correct and made available for staffs review. Program Specialist spoke to Rachel about this situation and offered her a key. Rachel expressed concern over being responsible for a key and stated that she liked things how they are currently. |
01/31/2024
| Implemented |