| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Individual # 1 does not have a completed Personal Property Inventory/record. | 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. | This regulation is important because it is a documented record of the individual's belongings. This allows the individual to have proof of their possessions so that if anything is missing it can be proved and replaced. Without an up to date list of what the individual owns or no longer owns, it is not possible to accurately keep track of their possessions and poses a risk of things going missing. The individual in this situation has been in the program for many years and had an inventory list completed at intake, which is our policy. Since this was years ago, this list is no longer available and it was not kept up to date with current possessions. This happened because Eagle Valley staff misunderstood the regulations and thought that it was required at intake, but did not continue the upkeep of this list. It is understood now that the property list must be ongoing and current to appropriately protect the individuals belongings. Staff have assisted the individual this past week in making an inventory list of all his current belongings. See attachment #4 |
10/06/2025
| Implemented |
| 6400.144 | Individual # 1 has a Bowel Movement Protocol which requires a "PRN of Polyethylene Gly 3350 after 48 hours of no BM and 24 hours of no BM after PRN to notify doctor". The agency is not tracking Bowel Movements as 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.
| It is important to track Bowel movements when a protocol is in place. This regulation is important because failure to follow up with the individual's health could cause the individual harm. This happened because staff did not realize that a formal tracking needed to be kept as the doctor did not request it and the individual tells staff when he is having an episode of constipation. He is not likely to be receptive to being asked on a daily basis if he has had a bowel movement, but will ask for help when needed. We reached out to his PCP and made them aware that the individual has not needed either of his two PRN constipation medications for over a year and his PCP agreed that they could be discontinued (discontinue orders received on 10/1 & 10/7). The individual continues to take two daily medications for constipation which have been effective in managing his constipation. His PCP also ordered termination of the bowel protocol on 10/3, and we received that paper order on 10/7 (Attachment #5). |
10/03/2025
| Implemented |
| 6400.182(a) | Individual # 1's assessment dated 01/01/25 indicates that Individual # 1 receives "bi-weekly labs to monitor their white blood cell count due to the medications that they are taking" On 01/07/25 the physician changed the frequency of lab work to once per month. The ISP last updated 07/31/25 reads "WEEKLY MONITORING FOR CLOZARIL THERAPY. CBCWDIFF." Labs were completed monthly on 02/03/25, 03/03/25, 04/28/25, 05/23/25 and 06/24/25. | The program specialist shall coordinate the development of the individual plan, including revisions with the individual and the individual plan team. | It is very important for revisions to the ISP to be kept up to date. This regulation is important because keeping the ISP up to date with current revisions is vital in better serving the individual's needs. The team needs to be aware of changes in the individuals needs so that appropriate care and services are offered. In this situation, the individual receives ongoing routine lab work. The doctor reviews his lab work at his appointments and identifies when he should return for his next labs. At the time of his 1/1/25 Annual Assessment, the individual had been getting lab work done bi-weekly. At his January 7, 2025 appointment he was told to return in 1 month and then that monthly frequency has continued. It was noted during inspection that the ISP contained a frequency of weekly that was out of date and had been missed in previous revisions. This happened because the Program Specialist missed making this revision to the ISP in previous revisions of the plan, and the outdated information did not get updated. |
10/01/2025
| Implemented |