| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Individual #1's ISP dated 7/2/2024 was not implement as written in the ISP. ISP states TV, video games, and other corded appliances should be covered in Plexi glass type material as Michael has a history of wrapping cords around his head/neck. During the walkthrough of the home there were multiple items was cords laying around such as the coffee pot, video games, tv, modem cables, phone cords, lamp cords, fans, headphones, and the door alarm. Per staff interviews on 9/5/2024 Michael will reach out for these cords and needs to be restrained. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | The plan has been updated to reflect the correct protective devices that have been implemented to ensure that he is unable to access cords that could hurt himself. The home was gone thoroughly threw and all accessible cords have been a fixed to a foundation or wrapped and secured so that they are at a short length and unable to be used for harm.
All staff have been trained on his new plan that was approved by the Human Rights Committee. |
10/04/2024
| Implemented |
| 6400.22(d)(1) | Individual #1 did not have a financial/property record completed until 6/12/24. DOA was 2/14/24. | 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. | Since this violation occurred, LCSS has had a new individual move into the agency. A property/financial record was completed on the date of admission. As part of the entry package¿ that must be conducted upon first day of admittance, the personal property inventory has been added to this file. Program specialist/manager has been trained on this new addition and the corresponding regulation. |
10/04/2024
| Implemented |
| 6400.43(b)(3) | Per violation 16 above the CE0 failed to implement polices and procedures for protection and safety of individual #1. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Safety and protection of individuals. | All plans have been reviewed by the CEO and the team to ensure that all areas are being implemented as written, especially the area of safety and protection. Corrections that were needed was sent to each person's supports coordinator for the updates to be made. |
10/04/2024
| Implemented |
| 6400.64(b) | At the time of the inspection there was an infestation of fruit flies in the kitchen. | There may not be evidence of infestation of insects or rodents in the home. | At the time of the inspection and the infestation was found, LCSS maintenance went to the home and sprayed the area. Since that time no fruit flies have been found and no source of where they were coming from have been found. |
10/04/2024
| Implemented |
| 6400.141(c)(13) | Individual #1's physical dated 9/6/2023 has allergies as NKDA. The face sheet and the ISP dated 7/2/2024 does not have allergies. Individuals MAR lists Loratadine diagnosis as seasonal allergies and Benadryl diagnosis as allergy symptoms. | The physical examination shall include: Allergies or contraindicated medications. | A new physical was completed on 09/12/2024 and allergies have been added appropriately. Face sheet was also updated to include this information. |
10/04/2024
| Implemented |
| 6400.20(c)(3) | The incident 9392991 involving individual #1's corrective actions were not implemented which could lead to possible harm. | The home shall identify and implement preventive measures to reduce: The likelihood of an incident recurring. | The plan has been updated to reflect the correct protective devices that have been implemented to ensure that he is unable to access cords that could hurt himself. The home was gone thoroughly threw and all accessible cords have been a fixed to a foundation or wrapped and secured so that they are at a short length and unable to be used for harm.
All staff have been trained on his new plan that was approved by the Human Rights Committee. |
10/04/2024
| Implemented |
| 6400.32(r) | Individual #1's rights document dated 2/14/2024 did not include the right to have a lock on the bedroom door. | An individual has the right to lock the individual's bedroom door. | At the time the violation was found, LCSS updated their individual rights document to include that every individual has the right to have a lock on their bedroom door. |
10/04/2024
| Implemented |
| 6400.165(a) | Individual #1's Chlopromaz 50mg Sept MAR states Dr. Lamer as prescriber. The Script states Dr. Krens. The Clonazepam 1mg Sept MAR states DR. Lamer as the prescriber. The Script states Dr. Krens. | A prescription medication shall be prescribed in writing by an authorized prescriber. | At the time of the violation, LCSS medical team reached out to the pharmacy to have this violation fixed. |
10/04/2024
| Implemented |
| 6400.182(c) | Individual #1 restrictive behavior plan dated 4/10/24 was not updated to reflect the most current ISP. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The plan has been updated to reflect the correct protective devices that have been implemented to ensure that he is unable to access cords that could hurt himself. The home was gone thoroughly threw and all accessible cords have been a fixed to a foundation or wrapped and secured so that they are at a short length and unable to be used for harm.
All staff have been trained on his new plan that was approved by the Human Rights Committee. |
10/04/2024
| Implemented |
| 6400.186 | Individual #1 ISP dated 7/2/24 does not cover the individual ability to handle money and manage finances. | The home shall implement the individual plan, including revisions. | The ISP and BSP have been updated to reflect this individual's ability to handle and manage his finances. |
10/04/2024
| Implemented |
| 6400.195(c)(6) | Individual #1's restrictive plan 4/10/24 did not include descriptions of the circumstances the use physical restraints can occur. | The behavior support component of the individual plan shall include: Types of restrictive procedures that may be used and the circumstances under which the procedures may be used. | At the time this violation was found, LCSS behavior specialist reviewed all plans, including this plan, and included a description of the circumstances that the use of physical restraint can be used. |
10/04/2024
| Implemented |
| 6400.207(4)(III) | Individual #1 takes Trazadone 100mg for Sleep and instructions for when to administer the medication as PRN are not included on the MAR. (very detailed description by physician and documentation) | A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: An ongoing program of medication. | At the time of this violation was found, LCSS medical personnel, contacted the prescribing doctor to get specific instructions on when to give and documentation was given to staff to clarify when this med is to be given and the circumstances in which it can be given. |
10/04/2024
| Implemented |