| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(c) | There were 3 bottles containing chemicals in unlabeled bottles. Two of them had writing on them, but no ingredient list. | Poisonous materials shall be stored in their original, labeled containers. | Labels were affixed to the bottle of cleaning solution; due to COVID-19 household cleaning supplies were not in supply therefore we ordered industrial size containers, and placed contents in spray bottles. The attached #2 Memo and verbal instructions to request a manufactures label if putting cleaning solution in an unmarked spray bottle, was directed to staff. |
09/25/2020
| Implemented |
| 6400.141(c)(10) | On INDIVIDUAL #1's Annual Physical Form dated 11/18/2019, INDIVIDUAL #1's Physician has indicated that he is not free of communicable diseases--the physician notes that he is a "Hep B Carrier." The remainder of the line is blank. The Physical Form does not list specific precautions to prevent the spread of disease; These precautions must be listed on the form. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | The attached #1 Physical form was updated with specific precautions that need to be taken due to the communicable disease to prevent the spread of the disease. A review of other forms revealed precautions were listed for other individuals. In hopes of preventing missed documentation the nurse and office personnel will review physical after medical appointment to make sure it's properly documented. |
09/30/2020
| Implemented |
| 6400.213(5) | INDIVIDUAL #1's Individual Record does not contain a Dental Hygiene Plan. | Each individual's record must include the following information: Dental hygiene plans. | We are using the oral hygiene information on the attached #3 dysphagia form for the dental hygiene plan as it contains the necessary details of type of assistance, how often brushing is done, and what mechanism is used(toothbrush, swab, toothpaste). The doctor visitation form for dental contained minimal dental hygiene plan information. All individuals have a annual dysphagia plan completed by the company nurse that includes the Dental hygiene plan. |
09/30/2020
| Implemented |
| 6400.166(b) | INDIVIDUAL #1's medication, Polyethylene Glycol, was not signed for on 8/4/2020 at 8pm. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Staff was reminded verbally and by memo to prior to completion recheck medications and medication log to make sure done accurately and completely. The attached #4 memo was sent to all staff who administer medication. Medication trainer responsible for meeting with staff, CEO sent memo. |
09/28/2020
| Implemented |
| 6400.195(c)(4) | INDIVIDUAL #1's Behavioral Support Plan, dated 04/01/2020, does not list a target date to achieve the outcomes listed. Target dates must be included. | The behavior support component of the individual plan shall include: A target date to achieve the outcome. | The attached #5 behavior support plan was updated to include the target date to achieve the listed outcomes. The other behavior support plans were reviewed and target dates were listed where needed. During quarterly review of behavior support plans target dates will be noted by program specialist. |
09/30/2020
| Implemented |