| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(b) | The hot water temperature was measured in the bathtub of the main bathroom at 122.6 degrees Fahrenheit. | Hot water temperatures in bathtubs and showers may not exceed 120°F. | The property manager of the apartment complex was notified of the water temperature. A request by the program manager was made to lower the temp. Staff immediately posted notes near the sinks/tub to ensure everyone was made aware to closely monitor the water until it was adjusted. Property Manager was able to come out the following morning and water temp adjusted. After two temp checks by program manager, postings were removed
Daily water temp logs were created and posted in all homes. Temp logs will be monitored by the Program Manager and Director. Monthly QA's will note any issues and/or concerns will irregular water temps. |
08/01/2022
| Implemented |
| 6400.113(a) | Individual #1 was admitted on 3/22/2021 and there is no record that they received fire safety training upon admission. | 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. | Program Manager completed fire safety training with individual following day, May 9, 2022. All home's fire safety trainings were reviewed to ensure that individual's trainings were up to date and compliant. |
08/15/2022
| Implemented |
| 6400.141(a) | Individual #1 was admitted on 3/22/2021 and did not have a physical examination until 10/2021. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Provider will ensure all individuals have an updated physical prior to admission to the program and annually thereafter. |
08/31/2022
| Implemented |
| 6400.141(c)(6) | Individual #1 was admitted on 3/22/2021 and did not receive a tuberculin skin test by Mantoux method with negative results until 10/21/2021. | 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. | Provider will ensure all individuals have a Tuberculin Skin Testing done prior to admission to the program and bi-annually thereafter. |
08/31/2022
| Implemented |
| 6400.142(a) | Individual #1 was admitted on 3/22/2021 and did not have a dental examination until 4/05/2022. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Provider will ensure all individuals have a dental exam completed every 6 months if they are 17 yrs or younger or annually if 18 yrs or older. |
08/31/2022
| Implemented |
| 6400.181(a) | Individual #1 was admitted on 3/22/2021 and the initial assessment was not completed until 6/18/2021 which was 89 days after admission. | 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. | The annual assessments will be completed by Program Specialist within 60 days of admissions and yearly thereafter. |
06/01/2022
| Implemented |
| 6400.181(d) | The annual assessment dated 3/22/2022 for Individual #1 was not signed by the Program Specialist. | The program specialist shall sign and date the assessment. | The annual assessments will be completed and signed by Program Specialist within 60 days of admissions and yearly thereafter. |
06/01/2022
| Implemented |
| 6400.181(e)(12) | The annual assessment dated 3/22/2022 for Individual #1 did not contain recommendations for specific areas of training, programming and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | The annual assessments was reviewed and revised by the new program specialist on May 2, 2022. The areas listed on reg 6400.181e was updated on the assessment and immediately replaced the old form. This incident occurred due to lack of knowledge of annual assessments being done by previous program specialist. |
08/01/2022
| Implemented |
| 6400.181(e)(14) | The annual assessment dated 3/22/2022 for Individual #1 did not document the individual's ability to swim. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | The annual assessments were reviewed and revised by the new program specialist on May 2, 2022. The areas listed on reg 6400.181e was updated on the assessment and immediately replaced the old form. This incident occurred due to lack of knowledge of annual assessments being done by previous program specialist. |
05/02/2022
| Implemented |
| 6400.165(c) | Individual #1 is prescribed Clonidine Hcl 0.2 mg. tablet, take 1 tablet by mouth at bedtime at 8PM. On 5/04/2022, the individual was administered this medication at 8AM instead of 8PM, and had a missed dose 5/04/2022 at 8PM. A prescription medication shall be administered as prescribed. | A prescription medication shall be administered as prescribed. | Provider filed EIM for med error, staff involved was retrained by med trainer. Individuals primary care physician was notified of the incident. |
05/05/2022
| Implemented |
| 6400.165(g) | Individual #1 is prescribed psychotropic medication and has been administered the medication since their date of admission on 3/22/2021. The individual had their first psychiatric medication review on 10/29/2021 which exceeds the 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. | The individual's medication regimen will be reviewed by the psychiatrist at least on a quarterly basis. Program Specialist |
06/01/2022
| Implemented |
| 6400.166(a)(13) | The Medication Administration Record (MAR) for May 2022 for Individual #1 did not include the names and initials of the staff who administer medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | Program Manager and Med Trainer were able to identify staff responsible by review of the schedules. Program Manager requested staff come in and complete documentation. Through conversation with staff, it was discovered that ear drops were dispensed as prescribed. |
08/15/2022
| Implemented |