| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | A self-assessment was not completed for this home. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| Completed self assessments will be sent to Department of licensing by end of work day April 5, 2024. |
04/05/2024
| Implemented |
| 6400.141(c)(14) | Individual #3 had a physical examination on 10/25/23 and the form did not include medical information pertinent to diagnosis and treatment in case of an emergency as this section of the form was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Program Specialist followed up with physician to review and revise documentation. All individuals files will be reviewed quarterly by Program Specialist |
04/05/2024
| Implemented |
| 6400.144 | 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. Individual #3 had an appointment on 4/27/23, and it noted to follow up in one month for Mea B#2 (Meningococcal Group B #2) in one month. There is no record of the appointment occurring. | 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 Specialist has followed up to ensure appointment was scheduled |
04/01/2024
| Implemented |
| 6400.32(r) | An individual has the right to lock the individual's bedroom door. Individual #3's bedroom door lock is a "privacy lock". This type of lock can be opened with a tool or device that is not specific to the particular door or lock; such as, a screwdriver or coin. These types of locks do not provide the level of privacy and security of person and possessions as expected by this regulation. | An individual has the right to lock the individual's bedroom door. | Program Manager followed up to ensure bedroom door lock was in compliance with regulatory bodies requirement. |
04/01/2024
| Implemented |
| 6400.165(g) | Individual #3 had psychiatric medication reviews on 2/14/24, 11/21/23, 9/13/23, and 6/28/23 and the form used did not include the reason for prescribing medication. | 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. | Program specialist reviewed the individuals files for accuracy. |
04/01/2024
| Implemented |
| 6400.169(a) | A staff person who has successfully completed a Department-approved medication administration course, including the course renewal requirements, may administer medications, injections, procedures, and treatments. The departments medication administration training program annual practicum requirements are two Mediation Administration Record (MAR)Reviews Completed within expected time frame in 1 year period (1 observation every 6 months), and Two Medication Observations Completed within expected time frame in 1 year period (1 observation every 6 months). Staff #3 had Modified Medication Administration Training Course completed on 10/14/22. There was no record or documentation of a competed Department's Initial Medication Administration Practicum in 2023. Staff #3 had an Annual Medication Practicum in their file however it only included one (1) Medication Administration Record (MAR) Review on 1/18/22 a Medication administration Observation on 1/18/22. Then 7/18/23, 1/18/24 observation checklist in Staff #3's record. Staff medication administration training is not being conducted and documented as prescribed by the medication administration training course. | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | Staff member was retrained by the trainer to ensure she is in compliance with med admin training procedures. |
04/01/2024
| Implemented |
| 6400.213(1)(i) | There was no photo in file for Individual #3 at the time of the inspection. | Each individual's record must include the following information: Personal information, including: (vi) A current, dated photograph. | Program Specialist attached photo and review all other individuals for compliance. |
04/01/2024
| Implemented |