| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | At time of inspection there was no up to date financial record for Individual #1. The last financial record noted to be in the Individual's file was date June of 2024. Individual #1 uses a debit card for purchases. Upon request bank statements from June 2024 to January 2025 were printed and provided on 2/12/25.
An up-to-date record of funds received by or deposited in the home were not maintained. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | Individual #1's bank statement records were provided during the inspection. Moving forward, the individual's bank statements will be attached to an ongoing ledger, along with all monthly receipts for every individual. Frontline supervisors have been trained and will be responsible for ensuring this process is consistently followed. The office manager will verify that this has been completed at the beginning of each month before filing the monthly financial records in their designated place in the office. |
03/04/2025
| Implemented |
| 6400.22(e)(3) | The Individual Support Plan for Individual #1 notes that they are able to carry $15 cash. At the time of inspection Staff #2 noted that Individual #1 does not use or keep any cash.
A review of bank records for Individual #1 printed on 2/12/25 noted cash withdrawals for $20 on 7/1/24, 7/15/24, 10/24/24, 12/2/24, 12/6/24, and 1/27/25. Bank records also recorded a cash withdrawal in the amount of $10 on 8/26/24.
Cash withdrawals were discussed with Staff #2 stating that the money was given to Individual #1 who would then take it to their program for spending.
Documentation that the cash was provided and used by Individual #1 was requested and not received.
For a withdrawal when the individual is given the money directly, the record shall indicate that funds were given directly to the individual. Documentation by actual receipt or expense record of the cash given to Individual #1 was not provided. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | Staff #2 was re-trained on the ISP by the program coordinator on the inspection day, 2/13/25. The program coordinator ensured that Staff #2 fully understands Individual #1's finances as outlined in the ISP. Moving forward, the program specialist will be responsible for ensuring that all staff and frontline supervisors are promptly informed of any updates documented in the ISP. |
02/13/2025
| Implemented |
| 6400.104 | The notification to the local fire department on file was dated 7/27/21. The letter indicates that the home is empty and was not updated to reflect the admission of individuals on 2/28/19 and 6/20/19. Notification to the local fire department must be kept current. | 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.
| CRHS updated and submitted all local fire department notifications for its residential sites on February 20, 2025. Moving forward, CRHS must update and submit these notifications annually or whenever there are changes to the home or the number of individuals residing there. |
02/20/2025
| Implemented |
| 6400.144 | Documentation indicates that Individual #1 attended a gastroenterologist appointment on 12/8/23 and was to "F/U in 3 months. Documentation indicates that the next appointment occurred on 7/12/24 and exceeded the recommended three-month time frame. Documentation from the 7/12/24 appointment notes to "return in 6 months." At time of inspection on 2/12/25 there was no documentation to support that an appointment had been attended within the 6-month time frame recommended. | 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.
| After Individual #1's 7/12/24 appointment, the doctor's office was supposed to send a recall letter to the address on file once it was time to schedule the next appointment; however, the letter was never received. A follow-up request for a 6-month appointment was sent on 2/14/25, but there was no response from the office. Another follow-up request was submitted, again with no response. On 3/5/25, a call was made to the office, and they confirmed that their system was not receiving the requests. The issue was escalated to their office manager, and Individual #1 was scheduled for the next available appointment on 5/16/25. To ensure and maintain compliance moving forward, CRHS has added a part-time nurse who will be responsible for following up on doctor's appointments. |
02/22/2025
| Implemented |
| 6400.214(b) | At the time of inspection, the most recent physical and assessment for Individual #1 were not in the home as required. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| The most current copies of record information required under § 6400.213(2)-(14) were immediately provided to the residential home from the office on the same day. The individual records are securely stored in the individual's folder, which is kept locked in the residential office space or the house's locked cabinet when not in use. |
02/14/2025
| Implemented |
| 6400.216(a) | At the time of inspection, the records for Individual #1 containing the Medication Administration Record, daily notes, dental visit form and additional items were located unlocked in the living room of the home. The records were stored in a hutch with glass doors and no locking device. | An individual's records shall be kept locked when unattended.
| The individual records book was immediately transferred to the office upstairs. The individual records are to be securely stored in the individual's folder and kept locked in the residential office space when not in use. |
02/13/2025
| Implemented |
| 6400.50(a) | Fire Safety training for Staff #1 and Staff #3 was documented as being provided by an outside fire safety company with a certificate of completion provided. The certificate noted that the training was for the use of fire extinguishers. During discussion of the content of the training with Staff #4 noted that the training encompassed other areas as required. Documentation of the content of the training was requested and not received. It could not be determined that the fire safety training covered location specific details such as the meeting place during a fire. Content of all trainings must be maintained as part of the training record. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | CRHS will ensure that the Fire Safety Company provides the annual fire safety training and offers more detailed information on the training content, as required by regulations. In addition to the training provided by Fire Safety by Expert, staff will also complete a site-specific training that covers location details, including, but not limited to, the designated meeting place during a fire. |
03/05/2025
| Implemented |
| 6400.52(c)(6) | There was no documentation to support that Staff #3 received training on the Individual Support Plan for Individual #1 as required. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | Staff #3 was re-trained on Individual #1 ISP immediately on the inspection day, 2/12/25. Moving forward, the Directors will ensure that the program specialist, staff, and frontline supervisors are trained on any updates documented in the ISP. |
02/12/2025
| Implemented |
| 6400.165(c) | At time of inspection a bottle of Chlorhexidine Gluconate was in use for Individual #1 with a record that it was delivered to the home and in use on 1/29/25. The bottle appeared to be near full. Label instructions noted that the medication was to be given "Rinse mouth w/ 1TBSP (15ml) X 30 seconds a 8am-8pm." The measuring device for the liquid was requested. A small shallow plastic cup was provided. The cup had no markings which would be used to measure the liquid as directed. The medication was not administered as prescribed. | A prescription medication shall be administered as prescribed. | Individual #1 had been using a previous bottle before the new one was opened and utilized. Med cups with markings up to 15ml were provided by the pharmacy. To ensure ongoing compliance, CRHS has added a part-time nurse responsible for following up on doctor's appointments and ensuring proper medication management. |
02/22/2025
| Implemented |
| 6400.165(g) | Documentation of medication reviews noted that they occurred on 6/29/24 and 11/1/24. This extends beyond the three-month time frame required. | 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. | Individual #1's psych appointment on 11/1/24 occurred later than scheduled due to rescheduling by the doctor's office. Any changes to medical appointments will be documented and kept in the individual's file to ensure compliance. To maintain compliance moving forward, CRHS has added a part-time nurse who is responsible for following up on doctor's appointments. |
02/22/2025
| Implemented |