| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | The couch in individual #1's game room had a broken base and the cushion was sinking | Floors, walls, ceilings and other surfaces shall be in good repair. | The couch for individual #1 has been remove from the game room and discarded. The noncompliance relates to furniture and not building surface. No building surface was attended to for this aspect of the licensure. Photo of the gameroom without the damaged couch is provided as exhibit-8 |
04/20/2019
| Implemented |
| 6400.77(b) | The First aid kit did not contain tweezers and antiseptic | 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. | A new first aid kit was procured to replace the one that fell short of compliance. The new kit has all assortments as per the regulations. Photo is hereby provided as exhibit-7. As an extension new first aid kits were procured for all homes so as to be compliant on the regulation in all homes. |
04/15/2019
| Implemented |
| 6400.113(a) | Individual #1's fire safety training was not signed by the individual. | 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. | Individual #1 has updated the fire safety training record with appropriate signature. Attached is the evidence as exhibit-6. All fire safety training record also inspected to update with appropriated signature of individual. |
05/05/2019
| Implemented |
| 6400.141(a) | Individual #1 last physical was 3/3/19 , which is more than a year from the previous physical dated 12/21/17. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual physical exam has been completed with mantoux and evidence provided as exhibit-5. A matrix has been created to capture all pending and current medical appointments and visits to serve as remedy to avoid repetition of non-compliance. |
04/09/2019
| Implemented |
| 6400.141(c)(6) | Individual #1's physical exam dated 3/3/19 did not include a Mantoux. | 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 annual physical exam for individual #1 was completed on MA51 form as earlier directed by county office. However following licensing, the physical was redone using the correct medical examinatin form as directed by licensing team. Mantoux is current and updated. Attached as exhibit-4 is the evidence. |
04/09/2019
| Implemented |
| 6400.167(b) | The medication, Pantoprazole 40 mg prescribed for individual 1 to be administered once a day for 14 days was not administered consecutively 14 days as prescribed. On March 1st and 2nd , 2019 it had not been administered. . | Prescription medications and injections shall be administered according to the directions specified by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Individual #1 made an out of state vacation to Atlantic City on March 1&2, 2019. Both medication and a duplicate copy of MAR accompanied individual#1. The medication was administered and recorded but the information was not transferred to the original MAR upon return from trip. Error has been acknowledged and incident report file. |
04/20/2019
| Implemented |
| 6400.168(a) | Staff person #1 administered medication, but there is no documentation to prove that the staff is trained in the department's medication administration training. | In a home serving eight or fewer individuals, a staff person who has completed and passed the Department's Medications Administration Course is permitted to administer oral, topical and eye and ear drop prescription medications. | Staff person #1 was trained to administer medication but the trainer had not returned the evidence and documentation of training up to licensing time. However, trainer was contacted and all training documents were provided and evidence herewith attached as exhibit-3. |
05/10/2019
| Implemented |
| 6400.181(d) | Individual #1 Assessment dated 12/24/18 but was not signed by the Program Specialist | The program specialist shall sign and date the assessment. | Assessment not being signed by Program Specialist was an oversight. The Program Specialist has signed the assessment report and correction is attached as evidence is labelled exhibit-2. |
05/10/2019
| Implemented |
| 6400.181(e)(5) | Individual #1 assessment dated 12/24/2018 did not include their ability to self-administer medications. | The assessment must include the following information: The individual's ability to self-administer medications. | As regards violation of 181e (5), the Individual medications have been administered by staff since coming over to Word of Life International. Currently individual has not been determined to self-medicate. If at any time during the future self- medication capability is established and he demonstrate the ability to be self medicated, he will be properly trained by our Medication Trainer and monitored by staff. The assessment has been updated with this corrected as an addendum. |
05/10/2019
| Implemented |
| 6400.181(e)(12) | Individual #1 assessment dated 12/24/2018 did not include recommendations for training, programming , and services. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | As regards violation 181e (12) There is no training recommended from the ISP at this time because Individual is not being self-medicated where training will be necessary for the self-medication process. Individual also does not attend any day program for skill training needs. The assessment has been updated with this correction as an addendum. |
04/10/2019
| Implemented |
| 6400.186(a) | Individual #1's ISP 3 month review that was due on June 2018 was not available for review. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the residential home licensed under this chapter with the individual every 3 months or more frequently if the individual's needs change which impacts the services as specified in the current ISP. | Reference violation 186a relating to the absence of June 2018 Quarterly ISP Review for individual #1, the practice has been that the Support Coordinator (SC) leads the team in conducting the quarterly ISP review. Following the meeting the SC summarizes and updates the ISP and shares with team. WLI always obtains the updated ISP. Going forward, and as a remedial action, WLI shall obtain the reviewed results in addition to the updated ISP. Exhibit-13 has been adopted for our first quarterly review following licensing. |
05/04/2019
| Implemented |