| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.80(a) | At the time of inspection, the sidewalk in front of the home's yard, the sidewalk leading from the front door of the home to the driveway, and the home's driveway were covered sporadically by thick patches of ice and snow, posing a fall risk. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | It snowed the day before the inspection on 1/21/2025, the snow was removed by UCCH snow contractor but there were some patches of ice on the sidewalk. The program manager and the DSP removed the patches of snow immediately after inspection on 1/22/2025 and salted the sidewalk to dissolve the leftovers to ensure the individual's safety. |
01/23/2025
| Implemented |
| 6400.165(g) | Individual #1 sees a psychiatrist for psychotropic medication management. The Psychiatry Appointment forms for the following dates did not include documentation of the need to continue each of the individual's psychotropic medications: 11/26/2024, 11/12/2024, 10/15/2024, 08/20/2024, 07/23/2024, 03/08/2024, and 01/19/2024. | 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 psychiatrist did not document the need to continue the individual psychotropic medications on the medication review form section. The medication review form has been simplified by UCCH CEO to indicate if the medication needs to be continued or not during a med review (this is a yes or no box that just needs to be checked off) for the psychiatrist. |
01/24/2025
| Implemented |
| 6400.166(a)(10) | Individual #1 is prescribed Metoprolol Succ Er 25mg Tab with instructions to "TAKE ONE TABLET BY MOUTH ONCE EVERY DAY FOR HYPERTENSION AT 9 IN THE MORNING." The entry for this medication on Individual #1's January 2025 Medication Administration Record (MAR) included a column for administration time to correspond with a row that staff write their initials in when administering the medication to Individual #1. Although the prescription for the medication noted that it was to be administered at "9 IN THE MORNING," the time column next to the staff's initials noted an administration time of 8:00am.
During medication administration, staff are able to administer the medication within 60 minutes prior to or 60 minutes after the time of administration. Staff signed for an 8:00am administration time from 01/01/2025 through 01/23/2025. Because the administration time on the log is 8:00am and because staff did not otherwise note an administration time at the time of administration, it could not be determined whether the medication had been given within 60 minutes prior to the medication's actual administration time of "9 IN THE MORNING" or if staff were utilizing the 8:00am administration time to determine the 60-minute administration window. The latter possibility could have resulted in staff administering the medication from 7:00am to 8:00am, which would have fallen outside of the actual window for this medication's administration. For this reason, the administration time in that column of the MAR should have been 9:00am. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | The administration time on the medication label (9am) was different from the administration time on the MAR (8am). At time the error was noticed, the pharmacy was called to notified them of the error and to get the correct time the medication is to be administered. The medication was discontinued on the MAR to reflect the time on the blister pack on 1/23/2024. |
01/23/2024
| Implemented |
| 6400.181(f) | An email found within Individual #1's Individual Record shows that the 03/20/2024 Individual Assessment was emailed to Individual Plan Team members on 01/08/2025. This Individual Assessment was not provided to the members of the individual's Individual Plan Team by the Program Specialist at least 30 calendar days prior to the individual's 01/15/2025 Individual Plan Team Meeting as required. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The Program Specialist provided the assessment to the individual plan team members which included the support coordinator on 1/8/2025, less than what the regulations specified days which is the 30 calendar days prior to the individual plan meeting, this will give the Support Coordinator enough time, to review and update the plan. Moving forward, the program specialist will update the individual assessment and send it to the individual support coordinator 30 days prior to the individual plan meeting. The assessment due date and E-Mail date shall be tracked by the program specialist and the quality manager to ensure compliance. |
01/24/2024
| Implemented |