| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The ceiling vent in the hallway of the home was covered in a thick layer of what appeared to be dust. The bathroom of the home smelled strongly of urine, with the bathroom rug soiled and discolored. The bedroom of Individual #1 smelled very strongly of urine with no definitive source.
(REPEAT VIOLATION 12/22, 3/23) | Clean and sanitary conditions shall be maintained in the home. | The Ceiling Vent in the hallway is now clean. a new bathroom rug was purchased to replaced the old one and the bath room is now clean. see picture of cleaned Ceiling Vent and new bathroom rug emailed to Kristen |
12/28/2023
| Implemented |
| 6400.141(c)(6) | Documentation indicates that the Mantoux for Individual #1 was completed on 11/12/21 then not again until 12/7/23. | 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 Agency has Implemented a chart with TB, Physical and Tdap due date. |
12/15/2023
| Implemented |
| 6400.141(c)(13) | The physical dated 12/7/23 did not contain allergy or contraindicated medication information. The section to be completed with the information was blank. | The physical examination shall include: Allergies or contraindicated medications. | The Program Director has written a letter to PCP's office notifying the Attending dr to ensure all areas of the Physical Exam form is completed. including the allergies/sensitivities and contraindicated medications. |
12/15/2023
| Implemented |
| 6400.142(e) | On 2/7/22 Individual #1 received a referral for restoration work on their teeth. There was no documentation to indicate that attempts had been made to schedule or have work completed until 1/26/23. Follow-up dental work shall be completed. | Follow-up dental work indicated by the examination, such as treatment of cavities, shall be completed. | The staff has been retrained to notify their supervisors of Individual refusal for an appointments. Individual has had oral dental follow up. see staff training sign-in and copy of most recent dental F/U emailed to kristen. |
12/18/2023
| Implemented |
| 6400.144 | Individual #1 attended a podiatry appointment on 3/30/23 and was to return in 2-3 months. There was no documentation to support that a follow up appointment occurred as recommended.
Individual #1 is prescribed Miralax powder and Dulea. Both medications were on the December 2023 Medication Administration Record (MAR) for Individual #1 but not available for use in the home. | 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.
| Program Director called to the podiatry's office and scheduled an other podiatry appointment for the Individual. see copy of Podiatry appointment completed on 12/21/23 emailed to Kristen.
Site supervisor reached out to doctor's office and obtained a new refill for Miralax powder and Dulcolax see attached medication received from Pharmacy emailed to kristen |
12/29/2023
| Implemented |
| 6400.163(h) | At time of inspection the Alcohol prep pads in use for Individual #1 had an expiration date of 11/23. Expired items shall be discarded. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The staff retrained to look at the expiration date of medication. The Expired Alcohol prep pads was returned to Pharmacy and an updated Alcohol prep was sent to the house. see copy of the updated Alcohol prep and staff training sign-in sheet emailed to Kristen. |
12/18/2023
| Implemented |
| 6400.165(c) | At time of inspection a Lorazepam prescribed to Individual #1 was found lying on the top of the medication tote, not administered.
(REPEAT VIOLATION 12/22) | A prescription medication shall be administered as prescribed. | The staff were retrained. EIM was entered for medication error. |
12/13/2023
| Implemented |
| 6400.165(g) | Medication review forms for Individual #1 were shared for reviews completed on 12/12/23, 8/29/23 and 5/24/23. The forms did not include all required information such as the dosage of the medication or the need to continue the medication.
(REPEAT VIOLATION 12/22) | 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 Agency has obtained a new 3 months psych meds review form which included the page for the dosage of the medication, the reason for prescribing the medication and the need to continue the meds. |
12/15/2023
| Implemented |