| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.143(a) | Individual #1 had a medication review via the telephone on 6/25/24, 7/17/24, 7/24/24, and 8/23/24 which he refused to pick up resulting in missing his medication review. Documentation of the missed appointments were documented, however the continued attempted to train the individual about the need for health care was not documented in the individual's record. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | On 12/12/24, Management held a meeting and went over the agency¿s policy on medical appointments, proper documentation of missed appointments, and steps to be taken when appointments are missed. In addition, CEO had a conversation with the resident about the advantages of keeping medical appointments including responding to phone calls from his therapist. |
12/12/2024
| Implemented |
| 6400.144 | Individual #1 had a medication review on 9/5/24. At this appointment the doctor requested the lab results from the bloodwork that was ordered in July 2024. Staff report not knowing about the bloodwork, at which time the doctor ordered new labs to be mailed to the individual's home. Individual #1 had a medication review on 11/7/24 at which time the doctor again ordered blood work due to individual reporting visual and auditory hallucinations. It appears from the documentation from the doctor's notes that the lab work was not completed on 2 separate occasions that the doctor ordered labs to test the individuals' levels. That was 4 months that the blood work was missed and at the time the blood work was drawn, in November 2024 the individual's Depakote levels, and vitamin D levels dropped, resulting in increasing medication dosage of Depakote and adding vitamin D. Health services such as lab work shall be provided for. | 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.
| As 12/12/24, A weekly checklist was created to track house manager¿s assignments including lab work or other referrals. The checklist is to ensure that all referrals or orders are completed as required. |
12/12/2024
| Implemented |
| 6400.151(a) | Staff should have a physical 12 months prior to employment and every two years after. Staff #1 date of hire was 3.29.21. Staff #1 had a physical dated 1/29/21, however there is no updated physical on file. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | On 12/12/2024, we created employee record tracker to ensure current or new employees are in compliance with ODP regulations. The documents to track are as follow: annual physical, training and others. |
12/12/2024
| Implemented |
| 6400.181(e)(12) | Individual #1 annual assessment dated 4/24/24 did not list recommendations for specific areas of training or program services. That area on the assessment was left blank. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | As of 12/13/2024, Program Specialist listed the recommendations on the annual assessment. |
12/13/2024
| Implemented |
| 6400.50(a) | Records of orientation and training shall be kept, including the training source, content, dates, length of training and copies of certificates. Staff #1 did not have record of orientation prior to working with the individuals documented. It was reported by the agency that staff #1 participated in the same orientation classes as the other employees however, employee #1 did not have documentation of said orientation. | 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. | As of 12/12/24, Management will ensure that all training attendees will complete new hire training and Employee orientation logs prior to being assigned to a program/individual. |
12/12/2024
| Implemented |