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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.151(a) | Direct Support Profession #1, date of hire 12/30/23, had a physical examination completed on 09/28/22 prior to employment. This exceeds 12 months prior to employment. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Direct Support Professional #1 was a staff from a temporary staffing agency. KZL Agency will notify staffing agency of requirement for physical examination to be no more than 12 months old when sending to work at KZL Agency. KZL Agency will request and review physical examination of all temp agency staff prior to allowing staff to work in the home, as is done with training records. This will be completed by KZL Agency's Personnel Manager, who is responsible for collecting all onboarding paperwork, including physical and TB test, prior to an employee¿s first day of work. |
08/14/2024
| Implemented |
| 6400.207(5)(III) | On 07/12/24 at 11:17 AM, Individual #1's bed contained full bedrails that restrict the movement or function of the individual's body. The agency does not currently have a prescription order from a physician for the bedrails. The most current assessment dated 01/22/24 does not include whether the individual "can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement." | A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Protection from injury during a seizure or other medical condition, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement. | KZL Agency completed the Mechanical Restraint Decision Tree located in the Chapter 6400 RCG. The results of the decision tree were that the bed rails were not considered a mechanical restraint as the individual plan allows for periods of relief from the device to allow freedom of movement. On 7/16/2024, KZL Agency received a faxed letter from the individual's PCP dated 7/12/2024 serving as an order for bed rails for safety purposes stemming from Kalen's extensive medical diagnoses. Upon receipt of this order, KZL Agency updated individual's Residential Assessment to reflect the need for bed rails. KZL Agency reached out to individual's SC to request an update be made to individual's ISP demonstrating the use of bedrails. This request was sent on 7/17/2024 with a second request being sent on 8/2/2024. KZL Agency received an email response from SC on 8/5/2024 stating that the update had been made to the ISP and that SC was awaiting plan be approved by an SC supervisor. As of 8/9/2024, documentation can be found in the General Health and Safety Risk section of individual's ISP. |
08/09/2024
| Implemented |
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