| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Individual # 1's financial ledger states that her current balance is $39.78. When reviewing deposits and withdrawals the amount Individual # 1 should have had was $39.73. | 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. | A financial flow sheet has been shared with each residential manager. All managers have been trained by , Assistant Director of Programs, on the consistency of documentation in all the residential homes. Each manager is and will continue to be responsible for ensuring all financial documentation is updated and accurate. For reference of the new form, please see attachment 7. All financial ledgers were updated for accuracy and consistency purposes throughout the organization and will continue being monitored by managers for accuracy going forward. |
01/03/2020
| Implemented |
| 6400.22(e)(1) | Individual # 1 moved in to her home on 2/25/19 and financial records weren't maintained until 11/13/19. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. | Going forward, the day that an individual moves into a J&FC home, the house managers will be responsible for creating a financial record on the first day they move in. Currently, there is a ¿NewHome Opening Action Steps document that serves as a checklist for what to do when new homes open and/or new individuals move in to a home. Create and file financial forms (wallet logs, food stamp logs, transaction logs)(Ensure this is done upon individuals move in date) has been updated on this form. Please see attachment 6 for more details. |
01/03/2020
| Implemented |
| 6400.110(f) | Individual # 2 who is hearing impaired utilizes strobe lights in her home in order to be alerted of a fire. In the front room/living room of her home doesn't have a strobe light | If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. | A strobe light will be installed in the front room of the home. Going forward, house managers will be responsible for ensuring all hearing imparied individuals have some way of being alerted of a fire; and that whatever that avenue is for alerting individuals is present throughout the home. A maintenance request for the addition has been submitted by Donna Runkle, Assistant Director of Programs. Target date for completion is 1/17/20. ordered a part for this job, but was sent the wrong detector from the supplier and is now waiting on the correct part to come in. Please see attachment 2 for proof of request to maintenance. |
01/03/2020
| Implemented |
| 6400.112(e) | A sleep drill wasn't held at least every six months. The home opened in February 2019 and a sleep drill wasn't conducted until October 2019. | A fire drill shall be held during sleeping hours at least every 6 months. | Going forward, a sleep drill will be scheduled every 6 months by the Assistant Director of Programs. The Assistant Director of Programs has created a yearly fire drill schedule, which is scheduled out through December 2020, that she will share with each manager. This schedule has sleep drills planned for April and October. For clarification, this schedule will only be shared with managers and the managers will ensure that the drills are unannounced (except to the person responsible for conducting the drill). Please see attachment 5 for reference. |
01/03/2020
| Implemented |
| 6400.112(h) | The designated meeting place wasn't reached during the fire drill conducted on 4/11/19. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | Going forward, if the meeting destination is not met in the appropriate amount of time, a 2nd fire drill will be conducted that month. The house managers will be responsible for this. The Assistant Director of Programs has created a fire drill schedule out until December 2020 and there is an ¿alternate date column on this schedule. For clarification, this schedule will only be shared with managers and the managers will ensure that the drills are unannounced (except to the person responsible for conducting the drill). Please see attachment 5 for reference. |
01/03/2020
| Implemented |
| 6400.112(i) | The smoke detector used during the fire drill conducted on 7/23/19 and 10/6/19 isn't specified on the fire drill log. | A fire alarm or smoke detector shall be set off during each fire drill. | Going forward, the staff who is assigned the responsibility of conducting the fire drill is responsible for filling out the fire drill form in its entirety and the program managers will be responsible for ensuring this is done. This includes specifying what smoke detector was used during each drill. For reference of a recent fire drill record that was completed in fullness, please see attachment 4. |
01/03/2020
| Implemented |
| 6400.144 | Individual # 1 is prescribed Mupirocin Ointment USP 2% PRN for her open sores and Acetaminophen tabs 500mg PRN for pain. Neither PRN medication was available at Individual # 1's home during this inspection. | 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.
| Residential manager, has acquired PRN medications and has stored them properly. Going forward, it will be the managers responsibility to ensure that necessary PRN medications are present in the home for when needed. Ensuring that all necessary meds are on hand is a checkbox on the newly implemented monthly medication checklist. Please see attachment 3 for reference. |
01/03/2020
| Implemented |
| 6400.152(c) | On 11/20/19 Individual # 1 was prescribed Aug Betamet Ointment 0.05% cream, twice daily for 14 days and then to be used as a PRN. This medication should have been discontinued on 10/4/19 for routine use and switched over as a PRN. This medication continued to be administered routinely twice a day until 11/14/19. | The physician's written instructions and precautions shall be followed. | Going forward, when a medication is prescribed for a specific amount of time and has a specific end date, the program manager will be responsible for ensuring this gets documented on the MAR through standard protocol to ensure it is clear to medication administrators that the medication is only to be administered until the specified date. If the med then switches over to a PRN, the manager will be responsible for ensuring a new entry on the MAR is filled out specifying that the med is a PRN. Checking to ensure that doctor¿s orders are being followed for all medications is a checkbox on the newly implemented monthly medication checklist. Please see attachment 3 for reference. |
01/03/2020
| Implemented |
| 6400.165(g) | Individual # 1 is prescribed psychotropic medications. Individual # 1 psychotropic medication was review on 5/22/19 but not again until 11/22/19. | 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. | Going forward, the house manager will take responsibility for scheduling the individuals appoitments. The mother will be invited to participate, but J&FC must take responsibility for ensuring the med is being reviewed as required. The last review was on 11/22/2019. The next is scheduled for 2/19/20. A monthly medication checklist has been added and ensuring psychotropic meds are being reviewed every 3 months is on that checklist. House managers will collaborate with the agencys nurse to ensure the checklist is routinely completed. Please see attachment 3 for reference. The house manager has also ensured that other psychotropic meds in the home have reviews scheduled within the required timeframe. |
01/03/2020
| Implemented |