| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(2) | Individual #1's financial ledger was not kept up to date. According to the his/her ledger, the ending balance from April 2017 was $31 and the begining balance that was carried over for May 2017 was $36.96. Individual #1 had two receipts for Clark Powells pizza, 4/27/17 for $6.98 and 4/28/17 for $6.99. However what was recorded on the ledger was "Clark Powells pizza 4/28/17 for $6.98" that did not match either receipt. The agency was not sure if both pizza receipts where for Individual #1. The ending balance for his/her May 2017 financial ledger was $23.96. His/Her June 2017 beginning balance that was carried over was $20.89 with no documentation of why the amounts were difffering. During the onsite inspection, according ot the amount of money recorded on the logs and the financial receipts provided, Individual #1 should have had $45.72. The financial ledger only indicated that he/she had $44.72. | (2) Disbursements made to or for the individual.
| The Executive Director retrained Program Specialists and Supervisors on the following regulation 22 (d)(2) on 10/30/17 as well as reviewed policies to be followed. See Attachment #21 |
10/30/2017
| Implemented |
| 6400.22(e)(3) | Individual #1's financial record indicated that on 8/4/17 clothes were ordered online for him/her for $178.61 however there was no documentation of the purchace by actual receipt. His/Her financial log also indicated that on 8/16/17 $40 was subtracted for "St.Michaels" but not indicated of what was purchased by itemized receipt. His/Her financial log also indicated that on 8/6/17, $50 was subtracted for "Steelers Camp" however there wasn't a receipt that coincided with the date, amount of money spent, or items purchased at Steelers Camp. There was a handwritten receipt in Individual #1's record for 8/6/17 "Steelers Camp: ate 2x souvenier flag" but did not have a cost on the hand written receipt. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | The Executive Director retrained Program Specialists and Supervisors on the following regulation 22 (e) (3) on 10/30/17 as well as reviewed policies to be followed. See Attachment #21 |
10/30/2017
| Implemented |
| 6400.44(b)(1) | The program specialist did not create the assessment. The home supervisor created Individual #1's assessment and the program specialist only reviewed it. | The program specialist shall be responsible for the following: Coordinating and completing assessments. | The Executive Director retrained Program Specialist and Supervisor on 10/24/17 on the following: Program Specialist shall be responsible for the following: Coordinating and completing assessments. See Attachment #20 |
10/24/2017
| Implemented |
| 6400.67(a) | The front porch and steps did not have a finished surface. Half of the outdoor carpet was ripped off the porch leaving an old glue surface and the carpet on the steps had many rips and frays. The refrigerator door handle was broken off. A drawer face was missing from one of the drawers on the bathroom vanity in the bathroom that Individuals #3 and #4 share. | Floors, walls, ceilings and other surfaces shall be in good repair. | Maintenance requests were submitted to the Business Administrator on 09/18/17. See Attachment (s) #19a, 19b & 19c |
10/20/2017
| Implemented |
| 6400.104 | The notification letter to the local fire department indicated the two males living at the home only required verbal assistance however they required verbal and physical assitance. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| An updated letter to the fire chief was sent 10/16/17 by Program Specialist. This letter includes the two males living in the home requiring physical prompts such as the bed shaker and strobes to evacuate the home in the event of a fire or fire drill. See Attachments #18a & 18b |
10/16/2017
| Implemented |
| 6400.110(f) | Individual #2 is hearing impaired and requires strobe lights in his/her bedroom. At the time of the inspection, Individual #2's strobe lights were not operable when the smoke detectors were activated. The strobe light devise was not plugged in. | If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. | Training was completed on 10/11/17 by Program Specialist for house supervisor and direct care support staff. If one or more individual or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. Individual #2 is hearing impaired and requires strobes in bedroom. The strobed was not operable when the smoke detector was activated. The strobe light device was not plugged in. Staff will check the strobe lights on a weekly basis with house supervisor monitoring the check list to ensure the strobe lights are plugged in and working. See Attachment(s) #17a & 17b |
10/11/2017
| Implemented |
| 6400.141(c)(11) | Individual #1's 9/9/16 physical examination form did not include an assessment of their health maintenance needs. The field was left blank. | The physical examination shall include: An assessment of the individual's health maintenance needs, medication regimen and the need for blood work at recommended intervals. | A physical exam was completed for individual #1 by the PCP on 09/11/17 which includes Health maintenance needs. The Supervisor will review individual physical exams to ensure all areas are completed as indicated. See Attachment #16 |
09/11/2017
| Implemented |
| 6400.141(c)(12) | REPEAT from 12/14/16 annual inspection: Individual #1's 9/9/16 physical examination form did not include physical limitations. The field was left blank. | The physical examination shall include: Physical limitations of the individual. | A physical exam was completed for individual #1 by the PCP on 09/11/17 which includes Physical Limitation. The Supervisor will review individual physical exams to ensure all areas are completed as indicated. See Attachment #16 |
09/11/2017
| Implemented |
| 6400.142(d) | Individual #1 had a dental cleaning on 3/16/7 and his/her dentist recommended 3 month recalls. At the time of licensing on 8/1617 he/she had not had a return appointment for a cleaning. | The dental examination shall include teeth cleaning or checking gums and dentures. | Training was completed on 10/11/17 by Program Specialist for house supervisor and direct care support staff. The dental examination shall include teeth cleaning or checking gums and dentures.
Staff will document each and every medical appointment the individual is scheduled for and keeps. Staff will document in medical entries when appointments may be rescheduled or cancelled with a valid reason the appointment has been changed. Staff will schedule and keep follow up appointments in the recommended time from the physician. The house supervisor will monitor appointments to ensure the appointments are documented and kept. See Attachment #15 |
10/11/2017
| Implemented |
| 6400.144 | Individual #1's dentist recommended upper dentures prior to May 2017. At the time of licensing on 8/16/17 Individual #1 did not have upper dentures completed with no documentation in their record for why he/she did not have dentures yet. Individual #1's doctor called in a script for an antibiotic on 7/5/17 and also indicated that he wanted to see Individual #1 in a few days. Individual #1 did not return to his/her doctor until 7/17/17 with no indication in the record why the follow up was not completed within a few days. Individual #1 had a psychiatric medication review completed on 2/15/17 in which he/she was to return in 6 weeks. He/She did not return until 4/24/17 with no indication in his/her record as to why the appointment was late. | 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.
| Training was completed on 10/11/17 by Program Specialist for house supervisor and direct care support staff. Staff will document each and every medical appointment the individual is scheduled for and keeps. Staff will document in medical entries when appointments may be rescheduled or cancelled with a valid reason the appointment has been changed. Staff will schedule and keep follow up appointments in the recommended time from the physician. The house supervisor will monitor appointments to ensure the appointments are documented and kept. See Attachment #15 |
10/11/2017
| Implemented |
| 6400.145(3) | The home's written emergency medical plan did not include an emergency staffing plan. | The home shall have a written emergency medical plan listing the following: An emergency staffing plan. | The home's written emergency medical plan was updated on 10/16/17 to include an emergency staff plan. See Attachment #14 |
10/16/2017
| Implemented |
| 6400.162(a) | According to Individual #1's August 2017 medication administration record, he/she was prescribed ear drops, instill 2 drops in each ear twice weekly on Wednesday and Saturday. At Individual #1's residence, there were two bottle of ear drops with two different medications labels. The medication label that indicated to instill 2 drops in each ear twice weekly on Wednesday and Saturday was expired in June 2017. The other container of ear drops had a medication label that indicated "dose: 2 drops in affected ears." There was two different medication labels on the ear drops in the home that did not match with relation to the dosage and frequency prescribed to Individual #1. | The original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual's name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. | Training was completed on 10/11/17 by the Medication Supervisor and Program Specialist with Direct Care Support Staff that the original container for prescription medications shall be labeled with a pharmaceutical label that includes the individual¿s name, the name of the medication, the date the prescription was issued, the prescribed dose and the name of the prescribing physician. The expired medication was immediately disposed of on 08/18/17 by two trained medication administration staff. The individual¿s PCP was contacted on 08/18/17 and the PCP discontinued the 2 drops in affected ears as well as 2 drops in each ear twice weekly on Wednesdays and Saturdays. The individual was then seen by his PCP on 08/21/17 with the PCP prescribing the Debrox ear drops 2 drops in affected ears daily (both left and right) for one week to loosen wax build up and then discontinue. The medication is no longer being administered. See Attachment #13 |
10/11/2017
| Implemented |
| 6400.163(c) | Individual #1's psychatropic medications were not reviewed properly on almost all of his/her medication reviews with his/her psychiatrist. The 7/20/17 appointment reviewed Risperdone 2mg once per day and he/she was actually prescribed 2mg twice per day, Benzatrope 5mg once per day and he/she was prescribed .5mg once per day, and Divalproex 500mg twice per day was not reviewed at all when it was prescribed as such. The 5/18/17 appointment reviewed Risperdone ".2mg" when it should have been 2mg twice per day, Beztropine ".5mg" when it should have been .5mg twice per day, Clonazepam ".5mg" when it should have been 1mg three times per day and .5mg in the morning, and Divalproex 500mg twice per day was not reviewed at all. The 4/24/17 appointment reviewed all medications were prescribed for "aggression" however Divalproex was prescribed for Bipolar disorder, Clonazepam for anxiety, and Risperdone for Mood disorder. The 12/28/16 appointment reviewed Risperdone "2mg daily in morning 1/2 by mouth" when it should have reviewed 2mg at night and 1mg in the morning, and Divalproex 500mg once a day and Aripiprazole 5mg once per day were not reviewed. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a review with documentation by a licensed physician at least every 3 months that includes the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Training was completed on 10/11/17 by Program Specialist for direct care staff to review the current medication administration log for the individual and indicate on the psychotropic review form the name of the medication, the reason for prescribing, the need to continue the medication and the necessary dosage to be reviewed by the psychiatrist. See Attachment #12 |
10/11/2017
| Implemented |
| 6400.164(a) | There was no time of administration on Individual #1's July and August 2017 medication administration record (mar) for when his/her ear drops were administered. There was no time of administration for Individual #1's Melatonin or Metformin either; only indicated "bedtime" and "supper" respectively. Individual #1's July 2017 mar did not indicate morning or evening for time of administration of amoxicillin. The only information recorded was "7:30, 12:00, 7:30. " | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | Direct care support staff were retrained by Medication Supervisor and Program Specialist on 10/11/17 to ensure the medication log listing medications prescribed, dosage, time and date that prescription medications, including insulin, were administered and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. See Attachment #12 |
10/11/2017
| Implemented |
| 6400.174 | The August 2017 menu available at the home was aproximately half completed for the entire month. The menu contained many blanks and it was unable to determine was food was provided to the individuals. For example lunch from 8/15-17/17, breakfast on 8/16/17 and 8/19/17, and some dinners were blank. | At least one meal each day shall contain at least one item from the dairy, protein, fruits and vegetables and grain food groups, unless otherwise recommended in writing by a licensed physician for individuals.
| Training was completed on 10/11/17 by Program Specialist for direct care support staff to document on the menu at least one meal each day to contain at least one item from the dairy, protein, fruits and vegetables and grain food groups unless otherwise recommended in writing by a licensed physician for individuals. House supervisor will be responsible to ensure this is completed by direct care support staff. See Attachment #11 |
10/11/2017
| Implemented |
| 6400.181(e)(5) | Individual #1's 3/12/17 assessment did not indicate if he/she could administer medications. His/Her assessment only indicated that he/she prefered staff to administer his/her medications. According to staff, he/she is not self medicating. | The assessment must include the following information: The individual's ability to self-administer medications. | The Assessment dated 03/12/17 for Individual #1 was updated with an addendum created by the Program Specialist on 10/24/17 to include the following correction.
INDIVIDUAL'S ABILITY TO SELF-ADMINISTER MEDICATIONS
Individual #1 does not have the ability to self- administer his oral medications and has reached their highest potential in this area at this time. He is capable of self-administering his lotion to both feet twice daily with an occasional verbal prompt. See Attachment #10 |
10/24/2017
| Implemented |
| 6400.181(e)(10) | Individual #1's 3/12/17 assessment did not include a lifetime medical history that was sent with the assessment. His/Her assessment was created and sent on 3/12/17 however his/her lifetime medical history was not created until 4/10/17. There was no indication in the record that the lifetime medical history was attached to the assessment and re-sent out to team members after it was created on 4/10/17. | The assessment must include the following information: A lifetime medical history. | The Executive Director retrained Program Specialists and Supervisors on the regulation on 10/24/17. The assessment must include the following information. A lifetime medical history. The assessment and lifetime medical history must be sent together and the lifetime medical history must be attached to the assessment. See Attachment #20 |
10/24/2017
| Implemented |
| 6400.181(e)(13)(ii) | REPEAT from 12/14/16 annual inspection: Individual #1's 3/12/17 assessment did not include his/her progress and current level of motor and communication skills. This was the same information as 2016 assessment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Motor and communication skills. | The Assessment dated 03/12/17 for Individual #1 was updated with an addendum created by the Program Specialist on 10/24/17 to include the following correction. Individual #1's progress over the last 365 calendar days and current level in Motor and Communication. See Attachment #10 |
10/24/2017
| Implemented |
| 6400.181(e)(13)(v) | Individual #1's 3/12/17 assessment did not include his/her progress and current level of socialization. This information was the same as what was in the 2016 assessment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Socialization. | The Assessment dated 03/12/17 for Individual #1 was updated with an addendum created by the Program Specialist on 10/24/17 to include the following correction. Individual #1'¿s progress over the last 365 calendar day and current level in Socialization. See Attachment #10 |
10/24/2017
| Implemented |
| 6400.181(e)(13)(vii) | REPEAT from 12/14/16 annual inspection: Individual #1's 3/12/17 assessment did not include his/her progress and current level of financial independence. This was the same information as 2016. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Financial independence.
| The Assessment dated 03/12/17 for Individual #1 was updated with an addendum created by the Program Specialist on 10/24/17 to include the following correction. Individual #1's progress over the last 365 calendar days and current level in Financial Independence. See Attachment #10 |
10/24/2017
| Implemented |
| 6400.181(e)(13)(viii) | REPEAT from 12/14/16 annual inspection: Individual #1's 3/12/17 assessment did not include his/her progress and current level of managing personal property. This information was the same as what was in the 2016 assessment. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | The Assessment dated 03/12/17 for Individual #1 was updated with an addendum created by the Program Specialist on 10/24/17 to include the following correction. Individual #1's progress over the last 365 calendar days and current level in Managing Personal Property. See Attachment #10 |
10/24/2017
| Implemented |
| 6400.181(e)(14) | Individual #1's 3/12/17 assessment did not include his/her ability to swim. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | The Assessment dated 03/12/17 for Individual #1 was updated with an addendum created by the Program Specialist on 10/24/17 to include the following correction. Individual #1's Ability to Swim. See Attachment #10 |
10/24/2017
| Implemented |
| 6400.183(4) | According to Individual #1's 3/12/17 assessment, he/she requires line-of-sight supervision in the community along with some physical assistance due to gait issues and crossing the streets. His/Her Individual Support Plan (ISP) did not indicate that he/she required physical assistance in the community. | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual's current assessment states the individual may be without direct supervision and if the individual's ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. | Individual Support Plan dated 06/30/17 for Individual #1 was updated with an addendum created by the Program Specialist on 10/24/17 to include the following correction.
Individual #1 needs line of sight supervision in the community along with some physical assistance with crossing streets and parking lots for safety purposes. See Attachments #8a & 8b |
10/24/2017
| Implemented |
| 6400.183(5) | Individual #1's Individual Support Plan (ISP) did not include a protocol to address all of his/her social, emotional and evironmental needs. His/Her protocol did not address his/her behaviors of mood swings, crying, verbal and physical aggression, being upset, and anxious. The protocol only addressed "anger." | The ISP, including annual updates and revisions under § 6400.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | Individual Support Plan dated 06/30/17 for Individual #1 was updated with an addendum created by the Program Specialist on 10/24/17 to include the following correction.
Changes made to the Support Plan: If Individual #1 is showing signs of anger, mood swings, crying, verbal or physical aggression, being upset or anxious, Staff will support Individual by encouraging to talk about what may be upsetting, take deep breaths, calm and relax. Suggest they remove self from what is bothering them. If individual is unable to calm, and becomes a threat to self or others, 911 is to be called immediately along with Crisis Intervention and either the home¿s supervisor or the on call supervisor to arrange for a staffing plan to be with individual at the hospital. See Attachments #8a & 8b |
10/24/2017
| Implemented |
| 6400.185(b) | Individual #1's Individual Support Plan (ISP) indicated that needs to use oxygen every night due to his/her oxygen levels dropping at night. The agency indicated that Individual #1 does not use his/her oxygen at night. There is no documentation in Individual #1's record that his/her refusal to use oxygen was discussed with doctors to ensure Individual #1's health and safety, nor is there a discontinue order. Individual #1's ISP doesn't indicate that he can self medicate any medication, however according to his/her medication logs, he/she has been self administering his/her Ammonium Lactate 12% lotiion apply to both feet daily. Individual #1's ISP indicates that he/she does left arm/hand exercises two time daily for range of motion. According to daily documentation logs, there are many days that are blank where the range of motion exercises were not completed; June 1st, 5th, 6th, 15th-17th, 23rd-26th, etc. Individual #1 has an outcome in his/her ISP to see a therapist two times per month. However he/she is not seeing a therapist and the agency is not sure if Individual #1 is still required to see a therapist. | The ISP shall be implemented as written. | Individual Support Plan dated 06/30/17 for Individual #1 was updated with an addendum created by the Program Specialist on 10/24/17 to include the following corrections.
1. Individual #1 is prescribed oxygen nightly by PCP due to oxygen levels dropping while sleeping. He/she has been refusing to use his oxygen and states he/she does not like the machine. Individual #1 was counseled on 09/05/17 by Physiatrist, 09/11/17 by PCP and 10/03/17 by Cardiologist of the importance of using the oxygen however each time Individual #1 refused to wear the oxygen. Individual #1 again met with Cardiologist on 10/20/17 and is in agreement to wear oxygen at night realizing it is needed to promote good health. Individual #1 will wear his oxygen nightly during sleeping hours and it will be documented nightly by support staff utilizing a check list.
2. Please indicate in the ISP that Individual #1 self-administers Ammonium Lactate 12% lotion apply to both feet daily
3. Please remove from ISP that Individual #1 sees a therapist two times per month. Individual #1 had in the past saw a therapist however has not had the need to go to therapy within the past year. Individual #1 does see his psychiatrist on a routine basis
See Attachments #8a & 8b
4. Support staff was re-trained by Program Specialist 10/11/17 on implementing the ISP as written and to follow written scheduled instructions when working on outcomes. Daily range of motion exercises to be done twice daily. See Attachment #9 |
10/24/2017
| Implemented |
| 6400.213(11) | Individual #1's Individual Support Plan (ISP) indicated that he/she was taking a daily insulin medication and that staff inject insulin daily for Individual #1. His/Her 3/12/17 assessment indicated that he/she was insulin dependent but al "insulin injection free." Individual #1 is no longer prescribed insulin and that has been discontinued since January 2017. Individual #1's ISP, lifetime medical history and 9/9/16 physical all indicated varying diet recommendations; his/her ISP indicated "no allergies," physical indicated sensitive to tomatos and byproducts, and the lifetime medical history indicated sensitives to spicy food, tomatos and byproducts, lactose intolerance, and diabetes. Individual #1's psychiatric medication reviews indicated he/she was prescribed divalproex for Mood disorder. His/Her ISP indicated it was prescribed for seizures, and his/he rmedication logs indicated it was prescribed for Bipolar Disorder. His/Her ISP did not indicated that he/she could handle any amount of money independenly however his/her 3/12/17 assessment indicated he/she could handle up to $20 independently. His/Her ISP indicated he/she was to follow a 1500 calorie diabetic diet when his/her 9/9/16 phsyical exam form indicated a 1500 low carbohydrate diet. | Each individual's record must include the following information: Content discrepancy in the ISP, The annual update or revision under § 6400.186. | See Paper
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10/24/2017
| Implemented |