| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(e)(1) | A June 2023 Financial ledger could not be produced for Individual #2. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. | A new cash on hand and SNAP form has been created and placed in use August 1, 2023. The forms were separated to ensure accuracy and proper account of all individual #2 funds. |
08/21/2023
| Implemented |
| 6400.22(e)(3) | Individual #2 is missing receipts for the following purchases from their Cash ledger: 5/15/23 at Redner's for 23.75, 5/22/23 for 22.37 which was noted as "shift count", 5/25/23 for $26.84 at Renders, and 5/27/23 for 17.71 at Redner's and Arbys. Individual #2 is missing receipts from purchases made on their Supplemental Nutrition Assistance Program (SNAP) card on 5/9/23 at Grocery outlet for $54.98 and on 5/12 for 15.94 at Redner's. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | Lost cash on hand receipts for individual #2 were found and kept accordingly in the individual¿s books according. Moving forward all petty cash receipts will be filled before mailing original copies to the individual¿s cash on hand forms. |
08/21/2023
| Implemented |
| 6400.62(c) | Poisons must be stored in their original labeled containers. At the time of the inspection, there was a homemade insect trap found on the windowsill in the kitchen. The trap consisted of an unlabeled plastic container which held an amber-colored liquid. According to staff, and verified by this inspector via smell, the main ingredient in the liquid seemed to be apple cider vinegar, but the staff stated that they believed that the trap also contained Dawn-brand liquid dish detergent, but it could not be verified with any degree of certainty. | Poisonous materials shall be stored in their original, labeled containers. | The homemade trap was trashed upon discovery during licensing |
08/21/2023
| Implemented |
| 6400.64(a) | In the shower/bathtub were 3 bars of used soap. It was unable to be determined which Individual uses which specific bar(s) of soap. | Clean and sanitary conditions shall be maintained in the home. | Bathroom caddies and lump soap box holder for both individuals have been put into use immediately after licensing on 7/26/2023. Each individual¿s initials have been written on both caddies and soap box holders. |
08/21/2023
| Implemented |
| 6400.67(a) | Floors, walls, ceilings, and other surfaces shall be in good repair. There were 2 loose drawer handle knobs located in the kitchen. | Floors, walls, ceilings and other surfaces shall be in good repair. | Both kitchen drawer knobs have been repaired and fixed on 8/4/2023. |
08/21/2023
| Implemented |
| 6400.181(e)(1) | The initial assessment completed on 3/08/2023 for Individual #2 did not document the individual's strengths, needs and preferences. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | Individual #2 next Annual Assessment will be updated and encompasses his strengths, needs and preferences and the updated copy will be filed in the individual¿s book. |
08/21/2023
| Implemented |
| 6400.181(e)(2) | The initial assessment completed on 3/08/2023 for Individual #2 did not document the individual's likes, dislikes and interests. | The assessment must include the following information: The likes, dislikes and interest of the individual. | Individual #2 next Annual Assessment will be updated and encompasses his likes, dislikes, and interests and the updated copy will be filed in the individual¿s book. |
08/21/2023
| Implemented |
| 6400.52(c)(3) | Staff #1 not receive annual training in Individual rights during the training year of 7/1/22-6/30/23. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Staff person #1 has completed training on Individual rights. |
08/21/2023
| Implemented |
| 6400.52(c)(6) | Staff #1 did not receive annual training in Implementation of the individual plan if the person works directly with an individual during the training year of 7/1/22-6/30/23. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | Staff member # 1 has completed ISP training and behavior support on the individual he is supporting. |
08/21/2023
| Implemented |
| 6400.165(g) | Individual #2 takes psychotropic medications to treat the symptoms of a diagnosed psychiatric illness. The individual currently does not have a psychiatrist (the individual is on a waiting list) and the psychiatric medications are being prescribed and reviewed by the individual's primary care physician. The record completed and signed for the reviews that occurred on 1/16/2023, 4/26/2023 and 7/05/2023 did not document all the psychotropic medications that the individual is prescribed, reasons for prescribing, dosage and the need to continue the medications. | 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. | A psych appointment for individual number one has been set for September 6, 2023 and his psych doctor will address his need to continue taking medication. |
08/21/2023
| Implemented |
| 6400.166(a)(11) | Individual #1's July Medication Administration Record (MAR) did not include the diagnosis or purpose for their medication Trazadone 50 mg. | 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. | Individual #1 Primary Care Physician was contacted, and a script was sent to the Pharmacy. The Pharmacy has sent a new MAR. |
08/21/2023
| Implemented |
| 6400.169(d) | A record of the training shall be kept, including the person trained, the date, source, name of trainer, and documentation that the course was successfully completed. Staff #1's Medication administration training date is recorded as 10/27/21. Staff #1 only completed 2 Medication Administration Observations on 10/27/21. Staff #1 then completed 2 more Medication Administration observations on 11/3/21. The initial Medication Administration class requires 4 medications observations. The date of completion was not kept correctly. The agency is not utilizing the Departments Medication Administration Training Programs Student Certification Form. The Student Certification Form includes documentation on the training completion date as well as indicates if the training is an initial or annual training. | A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. | A staff training on Medication Administration has been completed by staff member #1 |
08/21/2023
| Implemented |