Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.62(a) | Poisonous materials (cleaning material) were not kept locked, chemicals were in the bathroom cabinet under sink. | Poisonous materials shall be kept locked or made inaccessible to individuals. | LSHS has poisonous materials, chemicals (cleaning materials) kept locked in a safe place that the individual has no access to. Only staff personnel and their supervisors have access to such supplies in the event of cleaning at the individual's home. |
10/27/2022
| Implemented |
6400.70 | The home did not have a telephone with a outside line. | A home shall have an operable, noncoin-operated telephone with an outside line that is easily accessible to individuals and staff persons.
| LSHS CEO purchased and placed in every home a phone for the individuals and staff uses. In addition, LSHS assigned a cell phone in each home to implement community participation and serve as a backup/emergency. |
10/26/2022
| Implemented |
6400.77(b) | The first aid kit did not contain a thermometer. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | LSHS CEO purchased new first aid kits and put a first aid kit in each home. Further, overnight staff will check to ensure that all the required items are in each first aid kit. Also, staff will check the kit during the monthly fire drill. |
10/26/2022
| Implemented |
6400.112(a) | an unannounced fire drill was not held at least once a month. | An unannounced fire drill shall be held at least once a month. | The LSHS program manager has trained lead staff to implement an unannounced fire drill at least once a month. |
10/26/2022
| Implemented |
6400.112(d) | All fire drills extended past 2.5 minutes must be documented and re-tested to ensure consumers can safely evacuate.4/30/22, 5/30/22,6/29/22-3 mins long-no new drills taken | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | LSHS program manager and staff have received in-service training for implementing fire drills correctly to comply with 6400.112(d) regulation. |
10/26/2022
| Implemented |
6400.113(a) | Fire safety training for individual #1 is dated 5/30/22, which is two weeks after the date of admission. The fire safety training is to be completed at the time of admission and annually thereafter. | 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. | LSHS program manager completes Fire safety training for individual #1. The program manager will further ensure that fire safety training will be completed at admission and annually. |
10/26/2022
| Implemented |
6400.141(a) | The most recent physical is dated 7/14/22, which is two months after the individual #1 DOA (5/16/22). The physical before this most recent is dated 3/18/21. A physical must be dated 12 months prior to admission, then annually thereafter. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Moving forward, LSHS will ensure to comply with the regulations that any individual admitted to the LSHS program will have a physical that must be dated 12 months before admission, then annually. |
10/26/2022
| Implemented |
6400.141(c)(6) | There is no TB test for individual #1 on physical form dated 7/14/22. | 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. | Individual #1 has a schedule appointment to complete TB test, LSHS will pay out of pocket should there be any issue with the individual insurance. |
10/26/2022
| Implemented |
6400.141(c)(9) | There is no prostate exam for individual #1 on physical form dated 7/14/22. | The physical examination shall include: A prostate examination for men 40 years of age or older. | LSHS plans to correct this violation by ensuring that individuals#1 complete his prostate exam in the age of 40 years. |
10/26/2022
| Implemented |
6400.144 | Ind. #1 is a diabetic and is to have his blood tested utilizing the diabetic meter daily at 8am. The last time he was tested was 7/10/2022. Staff is logging the MAR as completed. | 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.
| LSHS plans to train all staff utilizing certified diabetes training. Following the training, staff will know how to log data on the MAR accurately. The program manager is responsible for carryout out this task. |
10/26/2022
| Implemented |
6400.144 | Medication POLYRTH LGYC POWDER for Ind. #1 is not being administered as prescribed. Staff is signing MAR as administered and individual stated he is not taking the medication based on the taste. | 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.
| LSHS plans to train all staff utilizing certified Meds Administration trainers. The training will teach staff how to document med administration accurately. The program manager is responsible and will supervise staff in the implementation of meds administration. |
10/26/2022
| Implemented |
6400.181(e)(10) | There is no lifetime medical history in the file for individual #1. | The assessment must include the following information: A lifetime medical history. | LSHS program specialist received in-service training regarding implementing all individuals' lifetime medical history and ensuring that the PC file and secure lifetime medical history in all individuals' medical files. |
10/26/2022
| Implemented |
6400.217 | There are no written consents in the file for individual #1. (This is required for the release of information, including photographs) | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| The LSHS program specialist received in-service training regarding implementing and ensuring that all written consents, such as the release of information, are secure in all individuals' files. |
10/26/2022
| Implemented |
6400.34(b) | There is no signed copy of rights for individual #1. | The home shall keep a copy of the statement signed by the individual, or the individual's court-appointed legal guardian, acknowledging receipt of the information on individual rights. | The LSHS program specialist received in-service training regarding implementing and ensuring that all contents, such as a copy of the rights of the individuals, are secure in all individuals' files. |
10/26/2022
| Implemented |
6400.52(b)(1) | CEO: did not have the required 12 hours of training. | The following shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons. | LSHS CEO has completed 12 hours of training to fulfill 6400.52(b)(1) regulations. |
10/26/2022
| Implemented |
6400.186 | The assessment states that poisons are to be locked, however the ISP states that poisons can remain unlocked. The information needs to be consistent. | The home shall implement the individual plan, including revisions. | LSHS program specialist will coordinate with the individual support coordinator to ensure to have consistency in the ISP and the individual program. |
10/26/2022
| Implemented |