| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(7) | Individual #1, date of admission 7/28/1998, had a recommendation by a doctor on 8/09/2016, for pap smears to be deferred indefinitely unless problems arise. Individual #1 has no documentation of a gynecological examination including a breast examination since 8/09/2016 and no documentation on deferment of the annual gynecological examinaiton. | 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. | 141c7 A Gynecological exam is required annually unless deferred by a Physician.
In this case the pap smear, was deferred due to the advanced age of individual #1. Her PCP was contacted for further technical assistance. Emmaus received a letter from the PCP on 10/12/23 indicating that Individual #1 no longer needs internal vaginal exams on a yearly basis. Continue yearly mammograms. This email communication was sent to ODP on 10/11/23 as well for notification. We received a printed format on letter head on 10/12/23. We will maintain this letter on individual #1's medical chart, from her PCP until otherwise noted. |
10/20/2023
| Implemented |
| 6400.142(f) | Individual #1 does not have a dental hygiene plan and Individual #1's assessment completed 5/16/2023 states she does need reminders to brush her teeth at night. Staff prompt the individual and often she refuses to floss her teeth, although recommend by her dentist. Staff assisted the individual in buying an electric toothbrush for gum health, but she does not wish to use it. She has at times flossed, when staff floss their own teeth beside her. She will use mouth rinse after brushing with staff prompts. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | A dental hygiene plan will be added on 10/20/23 as an addendum to individual #1's Annual Assessment originally dated 5/16/23. A step by step process for DSP's to follow will be included to better assist individual # 1 with dental hygiene and flossing. |
10/20/2023
| Implemented |
| 6400.163(h) | During the inspection conducted 9/27/2023, there was Diphenhydramine, Acetaminophen, and Ibuprofen identified in the first aid kit, which is kept in the first-floor, hallway linen closet unlocked and accessible to the individuals. Individual #1 and Individual #2 are both assessed to be unable to self-administer medications. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | The PRN medications within the First Aid Kit were removed on-site at the time of inspection on 9/27/23. The First kit remains in the first-floor, hallway linen closet unlocked so that the individuals #1 and #2 could access the kit as needed. Both individuals are not self-medicating so medications will not be within First Aid Kits at this home. All medications will remain locked in accordance with ODP. |
10/20/2023
| Implemented |