Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.22(c) | REPEAT 3/11/24- On 8/31/24, Individual #1's funds were used to purchase bedding, which is included in room and board. | Individual funds and property shall be used for the individual's benefit. | Individual has been reimbursed for the expenditure of bedding purchased on 8/31/2024. Check #47776 has been issued for $42.00 on 3/5/2025 for reimbursement of $22.00 for the comforter and $10.00 each for the 2 sheet sets Attachment #9a. Reimbursement amounts calculated by the controller. An email was sent by the program specialist to the agency on 3/7/25 that new bedding is not to be purchased with client funds under the average cost as specified by the controller office. Reimbursement of the average cost of bedding would be credited to the individual. Attachment #9b. |
03/10/2025
| Implemented |
6400.22(d)(1) | REPEAT 3/11/24- Individual #1's property record is not current and up to date. Individual #1 purchased two pieces of wall art totaling $296.78 that were not added to the personal inventory. Individual #1 purchased Ghost sneakers for 139.99 on 9/28/24. This item was not added to the inventory log. Individual #1 had a PAB Credit Card log in May 2024. $31.75 was spent and deducted from the balance of $331.85. The balance should have been logged as $300.10 but was documented as 299.60. This was not rectified. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | The current inventory for individual #1 was updated on 3/7/25 to include all items over $50 value and sentimental items and current inventory of individual's personal belongings Attachment#10a (4 pages). Financial ledger for the PAB gift card was not incorrect at the time of licensing. Attachment #10b. Citation states that $31.75 was deducted from $331.85, and the result was $299.60, however, the balance on the log reads $31.75 was deducted from $331.35 and there is no $0.50 discrepancy. All financial records are reviewed every shift change, by staff, to ensure accuracy. Discrepancies are to be reported to the program specialist immediately to ensure compliance. |
03/07/2025
| Implemented |
6400.22(e)(1) | REPEAT 3/11/24--Individual #1's FS balance increased from $722.37 on 8/31/24 to $967.37 on 9/24/24. No deposit was documented. The balance increased from 650.24 on 10/7/24 to 901.24 on 10/21/24. No deposit was documented. The balance increased from 133.18 on 10/31/24 to 384.18 on 11/23/24. No deposit was documented. The Snap balance increased from 157.78 on 11/30/24 to 408.78 on 12/26/24. | 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. | Deposit amounts were added to the SNAP ledgers by Program Specialist on 3/7/25 as late entries. Attachment #11a (3 pages). Snap ledger has been rectified to ***Staff will call in for a SNAP benefits balance every Friday. Indicate the deposits and balance inquiry on the ledger sheet weekly. *** by program specialist on 3/5/2025. Attachment #11b. |
03/10/2025
| Implemented |
6400.141(c)(7) | REPEAT 3/11/24-Individual #1 had a gynecology exam on 9/21/21 and not again until 12/20/24. Individual #1 is recommended to have a gynecological exam every three years. The exam was to be held by 9/21/24. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Program Specialist contacted the individual's healthcare provider and discussed the need for individual # 1 to have a Pap test, gynecological exam, and a breast exam on an annual basis on 3/7/25. The practitioner reviewed individual # 1's file and made the correct determination and indicated it in a letter stating the appropriate frequency for the examinations to be completed for this individual. The letter from the healthcare provider was added to individual's main file when received on 3/11/25 by program specialist. Attachment #12a. The electronic calendar, utilized by staff in the home, has been implemented and updated on 3/11/2025 by program specialist to reflect all appointments and due dates. Attachment #12c. Individual is scheduled for their next gynecological exam on 12/1/25, along with their annual physical. Attachment #12b. The need for a gynecological exam/ PAP test will be reviewed by the healthcare provider every year on the date of the physical exam. |
03/11/2025
| Implemented |
6400.143(a) | Individual #1 is to follow a 1500 calorie diet. There are many days that Individual #1's calorie intake exceeds the recommended amount. There is no documentation that Individual #1 is educated on the importance of following doctor's recommendations. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | All staff in-home were retrained on individuals mealtime plan and menu by program specialist on 3/7/25. Attachment #13a. Menu has been updated on 3/1/2025 by program specialist to include carb reduction. Attachment #13b (2 pages). Education documentation has been added to individuals goal for tracking and included in the training packet. Attachment #13c. Additional training in-house assigned on Relias platform to educate staff on diabetes management by program specialist on 3/7/2025 to be completed by 3/19/2025. |
03/19/2025
| Implemented |
6400.144 | Individual #1 is to follow a 1500 calorie diet. Staff are documenting Individual #1's calorie intake with each meal but are not consistently totaling up the calories to determine if the individual exceeded the recommended amount. Individual #1 has a blood sugar protocol that documents if their blood sugar exceeds 200, they are to limit their carbohydrates and increase their fluid intake. Individual #1's blood sugar levels were over 200 on the following dates: 3/13, 315, 3/16, 5/20, 6/29, 9/6, 9/12, 9/18, 11/14, 11/26, 12/7, 12/12, 12/26, 1/7, 1/22, and 1/27. There is no documentation that Individual #1's carbs were limited. Many times, the meals the individual ate on those dates were high in carbs. | 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.
| All staff in-home were retrained on individual's mealtime plan and menu by program specialist 3/7/2025. Attachment #13a. Menu has been updated on 3/1/2025 by program specialist to include a spot for documentation of carb reduction. Attachment #13b. Education documentation has been added to individuals' goal for tracking and included in the training packet. Attachment #13c. Additional training in-house assigned on Relias platform to educate staff on diabetes management by program specialist on 3/7/2025 to be completed by 3/19/2025. Staff will be trained on low carb foods by program specialist by 3/19/25. |
03/19/2025
| Implemented |
6400.145(3) | The emergency medical plan for Individual #1 does not document what the emergency staffing plan will be. | The home shall have a written emergency medical plan listing the following: An emergency staffing plan. | A new Emergency Medical Information sheet was created by DCQM on 3/3/2025 and updated companywide by the management team for all individuals in CRS care, to include names and phone contacts for all doctors. Emergency staffing plan updated to include current staffing plans, ambulance services and all medical contact information. Attachment #14a and #14b (2pages). Individuals current plan has been updated on 3/7/2025 by program specialist. |
03/19/2025
| Implemented |
6400.211(b)(3) | Individual #1's demographic information does not include the name, address, or phone number of who to contact for medical consent. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.
| Program specialist reviewed and updated individual's face sheet on 2/26/2025. Attachment #15a (2 pages). DCQM emailed management team to include emergency medical consent on face sheets for all individuals on 3/6/25. Clarification was noted on the emergency medical consent and contact information was added. Attachment #15b. |
03/06/2025
| Implemented |
6400.18(b)(2) | Individual #1 did not receive their pm dose of Risperidone on 5/24/24. Individual #1 did not receive their morning dose of Escitalopram on 6/30/24 or their morning dose of Perphenazine on 7/24/24. None of these med errors were reported to EIM. | The home shall report the following incidents, alleged incidents and suspected incidents through the Department's information management system or on a form specified by the Department within 72 hours of discovery by a staff person:
A medication error as specified in § 6400.166 (relating to medication errors), if the medication was ordered by a health care practitioner. | EIM's were entered in the HCSIS website by CRS incident manager on 2/26/2025. Attachment #16a (5 pages) and #16b (5 pages). Program Specialist and Supervisor were re-trained on reporting medication errors in the EIM system on 3/7/2025 by DCQM. Attachment #16c. |
03/08/2025
| Implemented |
6400.162(a) | Staff #1 did not receive medication administration training on alternative routes, specifically training on administering injections. Staff #1 did administer Individual #1 their Ozempic injection on 10/23/24, 11/20/24, and 12/18/24. | A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication. | Staff #1 was trained in Ozempic injections on 9/4/24, however the program specialist failed to provide proper documentation of the training at the time of licensing. All house staff are scheduled for retraining on 4/1/2025 by a licensed diabetes specialist. Attachment #17a (2 pages) and #17b. All Ozempic injection administrations will be given only by those who have their current injection training status. If staff working in home on days individual required her injection, program specialist or program supervisor will be on site to administer her medication. |
04/01/2025
| Implemented |
6400.162(b)(2)(vi) | Staff #1 did not receive medication administration training on alternative routes, specifically training on administering injections. | A prescription medication that is not self-administered shall be administered by one of the following: A person who has completed the medication administration course requirements as specified in § 6400.168 (relating to medication administration training) for the administration of the following: Medications, injections, procedures and treatments as permitted by applicable statutes and regulations. | All house staff are scheduled for retraining on administering injections on 4/1/2025 by a licensed diabetes specialist. Attachments #17a (2 pages) and #17b. All Ozempic injection administrations will be given only by those who have their current injection training status. If staff working in home on days individual required her injection, program specialist or program supervisor will be on site to administer her medication. |
04/01/2025
| Implemented |
6400.167(a)(1) | Individual #1 did not receive their pm dose of Risperidone on 5/22/24. There was a checkmark in the slot. Individual #1 did not receive their morning dose of Escitalopram on 6/30/24 or their morning dose of Perphenazine on 7/24/24. | Medication errors include the following: Failure to administer a medication. | EIM's were entered in the HCSIS website by CRS incident manager on 2/26/2025 Attachment #16a (5 pages) and #16b (5 pages). It was discovered that individual #1 did receive their Risperidone on 5/22/2024, however staff documented the administration on the MAR incorrectly, using a check mark. Staff was re-trained on proper documentation of medications on 3/7/2025 by program specialist. Attachment #18a. Two staff involved are sub aide status. One sub aide is on medical leave and will be retrained on 3/26/2025 prior to returning to work. The other sub aide is also on medical leave and has been notified via phone that they will be required to complete retraining prior to returning to work. |
03/26/2025
| Implemented |