| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(c) | Fire drills held on 11/22/21, 12/22/21 and 3/31/22 did not record the time it took for evacuation. Fire drills held on 11/22/21 and 12/22/21 did not indicate AM or PM for time of day. Both drills recorded the time of drill as 1:30. There was no additional information on the fire drill form that would indicate whether the drill was held during AM or PM hours. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | The fire drills forms in question were reviewed and corrected. |
08/25/2022
| Implemented |
| 6400.141(a) | Individual #1 was admitted into the program on 11/19/21. The physical presented for Individual #1 was completed on 12/3/21. Physicals must be completed within 12 months prior to admission. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | The individual¿s physical was reviewed and completed again by his Primary Care Physician (PCP) with the ODP approved form for individual physicals. |
08/25/2022
| Implemented |
| 6400.141(c)(1) | The physical presented for Individual #1 was completed on 12/3/21. Documentation on the physical did not contain a review of previous medical history. | The physical examination shall include: A review of previous medical history. | The individual physical was reviewed and completed again by his Primary Care Physician (PCP) with the ODP approved form for individual physicals. The individual¿s previous medical history was added on the review and completion. |
08/25/2022
| Implemented |
| 6400.141(c)(2) | The physical presented for Individual #1 was completed on 12/3/21. Documentation on the physical did not contain information to support that a general physical exam had been completed. | The physical examination shall include: A general physical examination. | The individual¿s physical was reviewed and completed by his Primary Care Physician (PCP) with the ODP approved form for individual physicals. The completed physical is attached with all supporting documents. |
08/25/2022
| Implemented |
| 6400.141(c)(3) | The physical presented for Individual #1 was completed on 12/3/21. Documentation on the physical did not contain a verification that immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control had been completed. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | The individual¿s physical was reviewed and completed by his Primary Care Physician (PCP) with the ODP approved form for individual physicals. The physical contained the individual¿s immunization record. |
08/25/2022
| Implemented |
| 6400.141(c)(6) | The physical presented for Individual #1 was completed on 12/3/21. Documentation on the physical did not contain verification that Tuberculin skin testing had been completed as required. | 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. | The individual¿s physical was reviewed and completed by his Primary Care Physician (PCP) with the ODP approved form for individual physicals and the form completed indicated that Tuberculin and skin testing was completed. |
08/25/2022
| Implemented |
| 6400.141(c)(11) | The physical presented for Individual #1 was completed on 12/3/21. Documentation on the physical did not contain an assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | The individual¿s physical was reviewed and completed again by his Primary Care Physician (PCP) with the ODP approved form for individual physicals and the form completed also indicated an assessment of the individual¿s health maintenance needs, medication regiment and the need for blood work recommendation intervals. |
08/25/2022
| Implemented |
| 6400.141(c)(12) | The physical presented for Individual #1 was completed on 12/3/21. Documentation on the physical did not contain a review of the physical limitations of the Individual. | The physical examination shall include: Physical limitations of the individual. | The individual¿s physical was reviewed and completed by his Primary Care Physician (PCP) with the ODP approved form for individual physicals. The new completed form contained a review of the physical limitations of the individual. |
08/25/2022
| Implemented |
| 6400.141(c)(13) | The physical presented for Individual #1 was completed on 12/3/21. Documentation on the physical did not contain information pertaining to allergies or contraindicated medications. | The physical examination shall include: Allergies or contraindicated medications. | The individual¿s physical was reviewed and completed again by his Primary Care Physician (PCP) with the ODP approved form for individual physicals. The new form completed contained information pertaining the individual¿s allergies or contraindicated medications. |
08/25/2022
| Implemented |
| 6400.141(c)(14) | The physical presented for Individual #1 was completed on 12/3/21. Documentation on the physical did not contain medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The individual¿s physical was reviewed and completed again by his Primary Care Physician (PCP) with the ODP approved form for individual physicals. The new completed form contained medical information pertinent to the individual¿s diagnosis and his treatment as well in emergency situations. |
08/25/2022
| Implemented |
| 6400.141(c)(15) | The physical presented for Individual #1 was completed on 12/3/21. Documentation on the physical did not contain special instructions for the individual's diet. | The physical examination shall include:Special instructions for the individual's diet. | The individual¿s physical was reviewed and completed again by his Primary Care Physician (PCP) with the ODP approved form for individual physicals. The new completed form contained special instructions for the individual¿s diet. |
08/25/2022
| Implemented |
| 6400.151(c)(3) | The physical exam presented for Staff #1 that was completed on 12/28/21 did not contain a signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | The staff¿s physical was reviewed and the Doctor that did the initial physical. The new completed form contained a signed statement that the staff person is free of communicable diseases. |
08/25/2022
| Implemented |
| 6400.181(a) | Individual #1 was admitted into the program on 11/19/21 and had an initial assessment completed on 12/9/21. The assessment completed was primarily a checklist. The required sections of Lifetime Medical History, Strengths, Dislikes, Supervision needs, Health, Recreation, Managing Personal Property and Community Integration were either missing or lacked adequate information. The assessment lacked personalization and was not individualized. The assessment cannot be vague or nonspecific. Assessments cannot be completed simply to meet the regulatory or programmatic requirements. Providers must develop assessments that are meaningful, accurate, and useful. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | Another annual assessment was completed on 8/3/2022 by the agency Program Specialist. The required sections of the individual¿s Lifetime Medical History, Strengths, Dislikes, Supervision needs, Health, Recreation, Managing Personal Property and Community Integration were personalized based on the individual¿s goals and outcomes. |
08/25/2022
| Implemented |
| 6400.34(a) | Incomplete review of individual rights for Individual #1 was completed on 11/19/21. The following rights were not reviewed: 6400.34D, E, F, G, I, P, Q, R, S, T, U and V. Full review is required to satisfy the regulation. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | A staff training on all individual rights statement has been completed on 8/15/2022. The individual was trained as well on his rights. |
08/25/2022
| Implemented |
| 6400.163(a) | At time of inspection on 7/27/22 a prescription Glucagon Emergency Kit was in the locked medication box of Individual #1. There was no pharmacy label on the Glucagon Emergency Kit. At time of inspection on 7/27/22 a prescription Baqsimi Glucagon nasal powder 3mg was in the locked medication box of Individual #1. There was no pharmacy label on the Baqsimi.
Staff #4 confirmed that both medications belonged to Individual #1. | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | All individual¿s old medication has been returned to the Pharmacy immediately after licensing. Individual¿s Doctors were contacted for new scripts with all medications in question. The Pharmacy was also contacted for new med label with only current medications. All agency staff has been re-trained on PA medication administration training on 8/04/2022. |
08/25/2022
| Implemented |
| 6400.163(h) | At time of inspection on 7/27/22 a Glucagon Emergency Kit that lacked a pharmacy label was located in the locked medication box for Individual #1. The expiration date on the Glucagon Emergency Kit box was 12/2021. An Epinephrine Injection, USP Auto Injector 0.3 mg was located in the locked medication box for Individual #1. The pharmacy label indicated "Discard after 6/28/22." Expiration date on the box was Mar of 2023. Pharmacy label directions are to be followed. Expired medication shall be discarded promptly and as directed. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | All individual¿s old medication has been returned to the Pharmacy immediately after licensing last month. Individual¿s Doctors were contacted for new scripts with all medications in question. The Pharmacy was also contacted for new med label with only current medications. All agency staff has been re-trained on PA medication administration training on 8/04/2022. |
08/25/2022
| Implemented |
| 6400.165(b) | Individual #1 Individual Support Plan last updated on 7/27/22 indicates that Individual #1 has a shellfish and tree nut allergy both with a reaction of throat swelling. The assessment for Individual #1 dated 12/9/21 indicates that Individual #1 has a tree nut allergy with a reaction listed as "Anaphylaxis." An Epinephrine Injection, USP Auto Injector 0.3 mg was located in the locked medication box for Individual #1 at the time of inspection. The pharmacy label indicated "Discard after 6/28/22" and "Refill 3 times until 06/27/2022." The prescription for the Epinephrine Injection, USP Auto Injector 0.3 mg was not current. A prescription order shall be kept current. | A prescription order shall be kept current. | The individual¿s Primary Care Physician was contacted immediately for a script for his Epinephrine. A script was sent to the Pharmacy and new Epinephrine has been delivered to his home. All agency staff members has been re-trained on PA medication administration training on 8/04/2022. |
08/25/2022
| Implemented |
| 6400.165(g) | Individual#1 had three-month medication reviews on 5/23/22, 3/28/22 and 4/25/22. The 5/23/22 medication review did not record the dosages of the medications. The 3/28/22 medication review did not include the dosages for Buspirone, Effexor or Abilify. | 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. | Individual¿s Psychiatrist has completed another Med review form that includes the dosages the reasons for all his psych medications and the need for him to continue with his current psych medications. |
08/25/2022
| Implemented |
| 6400.166(a)(7) | The July 2022 Medication Administration Record (MAR) for Individual #1 has an entry for Novolog. The entry is recorded as "Insulin ASPA INJ Flexpen For: Novolog as per sliding scale." The July 2022 MAR for Individual #1 does not indicate the dose of the medication. The pharmacy label documents the medication as "Use carb ratio 1:5 with meals plus sliding scale. TDD to 60 units. (DX:Type 1 diabestes mellitus without complications.) | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | The individual¿s Endocrinologist was contacted immediately after licensing for a script with the correct information for his Novolog dosage. His Endocrinologist sent a medical statement explaining why his insulin can only be administered during his meals times and carb ratio. The scrip and the medical statement is attached with all supporting documents. |
08/25/2022
| Implemented |
| 6400.166(a)(8) | The July 2022 Medication Administration Record (MAR) for Individual #1 has an entry for Novolog. The entry is recorded as "Insulin ASPA INJ Flexpen For: Novolog as per sliding scale." The July 2022 MAR for Individual #1 does not indicate the route of administration. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | The individual¿s Endocrinologist was contacted immediately after licensing for a script with the correct information for his Novolog dosage. His Endocrinologist sent a medical statement explaining why his insulin can only be administered during his meals times and carb ratio. The scrip of the medication attached indicated subcutaneously as the the route of the medication. The Pharmacy was notified of the and has been added on the new MAR. |
08/25/2022
| Implemented |
| 6400.166(a)(9) | The July 2022 Medication Administration Record (MAR) for Individual #1 has an entry for Novolog. The entry is recorded as "Insulin ASPA INJ Flexpen For: Novolog as per sliding scale." The July 2022 MAR for Individual #1 does not indicate the route of administration.
The July 2022 Medication Administration Record (MAR) for Individual #1 has an entry for Novolog. The entry is recorded as "Insulin ASPA INJ Flexpen For: Novolog as per sliding scale." The July 2022 MAR for Individual #1 does not indicate the frequency of the administration. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | The individual¿s Endocrinologist was contacted immediately after licensing for a script with the correct information for his Novolog dosage. His Endocrinologist sent a medical statement explaining why his insulin can only be administered during his meals times and his carb ratio and no specific times. The scrip and the medical statement is attached with all supporting documents. |
08/25/2022
| Implemented |
| 6400.166(a)(11) | The July 2022 Medication Administration Record (MAR) for Individual #1 has an entry for Novolog. The entry is recorded as "Insulin ASPA INJ Flexpen For: Novolog as per sliding scale." The July 2022 MAR for Individual #1 does not indicate the diagnosis or purpose of the medication.
The July 2022 MAR for Individual #1 did not include diagnoses for Aripiprazole, Fish Oil, Lantus, Levocetirizine, Lisinopril, Flonase, Prilosec, Melatonin, Methylphenidate, Montelukast and Venlafaxine. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | The individual¿s Endocrinologist and his Primary Care Physician were contacted immediately after licensing for a script with the correct information for his Novolog dosage. His Endocrinologist sent a medical statement explaining why his insulin can only be administered during his meals times and carb ratio. The scrip of the medication attached indicated diabetes as the diagnosis or purpose of the medication. The Pharmacy was notified and an addition has been made as well on new MAR for all his current medications. |
08/25/2022
| Implemented |
| 6400.169(b)(2) | July 2022 Medication Administration Records (MARs) for Individual #1 record that Staff #4 administered Lantus injections on 7/8/22 and 7/9/22. July 2022 MARs also record that Staff #4 administered Novolog injections at 8am on 7/8/22, 7/15/22 and 7/18/22. Medication Administration training records for Staff #4 indicate that they were currently certified to administer medications. Review of training records also indicated that Staff #4 received training on Diabetes on 4/28/22 through the Advocacy Alliance which is not a department approved diabetes patient education program. Staff #4 did not meet the qualifications to administer insulin injections as completion of the Department approved medication administration course as well as a Department-approved diabetes patient education program were completed within the past 12 months.
Staff #1, #5, #6, #7, #9, #10 and #11 all initialed the July 2022 MAR for Individual #1 to indicate that they had administered doses of Novolog to Individual #1. Reports by Staff #4 and Staff #2 at time of inspection indicated that all staff were trained in Diabetes by The Advocacy Alliance; documentation of the training was requested. Documentation of the training by The Advocacy Alliance or a Department approved diabetes education program was not provided. Diabetes training by The Advocacy Alliance does not satisfy regulation as it is not a Department approved diabetes education program. Training by a Department approved diabetes patient education program within the past 12 months in addition to training as outlined in 6400.169 b1 are required to satisfy regulation and provide staff with necessary training to administer insulin injections as required.
Staff #1, #4, #6, and #7 all initialed the July 2022 MAR for Individual #1 to indicate that they had administered doses of Lantus to Individual #1. Reports by Staff #4 and Staff #2 at time of inspection indicated that all staff were trained in Diabetes by The Advocacy Alliance; documentation of the training was requested. Documentation of the training by The Advocacy Alliance or a Department approved diabetes patient education program within the past 12 months in addition to training as outlined in 6400.169 b1 are required to satisfy regulation and provide staff with necessary training to administer insulin injections as required. | A staff person may administer insulin injections following successful completion of both: A Department-approved diabetes patient education program within the past 12 months. | As of 7/28/2022 only licensed medical professionals were allowed to inject insulin to all agency individuals only. Agency staff members may administer insulin injections after a successful completion of a department-approved diabetes patient training. |
08/25/2022
| Implemented |