| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | Individual#1' funds are not being used for his individual's benefit. On 2/4/24 Individual #1 made a purchase at Walmart for $17.30 that included a sheet set for $9.44 and 2 Comfort Plw for $3.44 each. These items should not be purchased using individual's funds as they would be included in Room and Board. | Individual funds and property shall be used for the individual's benefit. | Reimbursement for individual was requested for the purchase of the sheets and pillows on 12/20/2024. |
12/30/2024
| Implemented |
| 6400.22(e)(3) | According to Individual #1's Individual Support Plan (ISP) last updated 10/23/24 they need total/full physical assistance with managing money and personal finances. Individual #1's receipt from a 3/16/24 purchase at Rosario's for $19.07 was missing. | 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. | Since the receipt could not be located or obtained, a request for reimbursement was submitted.. |
12/30/2024
| Implemented |
| 6400.106 | The furnace was cleaned on 2/14/23 and no documentation or record that one has occurred since. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| The home was added to the annual inspection list for the furnace cleaning provider used by EIHAB. |
12/30/2024
| Implemented |
| 6400.151(a) | Staff #1 had a physical examination on 12/21/21, and there is no record that one has occurred since. | 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. | Staff subsequently went out on medical leave but will not be allowed to work in the homes before obtaining a current staff physical. |
12/30/2024
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medication to treat symptoms of a diagnosed psychiatric illness. Individual #1 had a psychiatric medication review on 9/12/24, and the form used does not include documentation that it was reviewed by a licensed physician, such as a signature, as this section was left blank. The only documentation of a signature on the form was an electronic signature from the agencies staff. Agency provided a fax dated 12/6/24 to the licensing representative from the licensed physician including their signature on Individual #1's psychiatric medication form from 9/12/24 as their plan of correction to the identified issue/citation on 12/3/24. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Physician signature was obtained on the form on 12/3/24. |
12/30/2024
| Implemented |
| 6400.169(a) | A staff person who has successfully completed a Department-approved medication administration course, including the course renewal requirements, may administer medications, injections, procedures, and treatments. The departments medication administration training program annual practicum requirements are two Mediation Administration Record (MAR)Reviews Completed within expected time frame in 1 year period (1 observation every 6 months), and Two Medication Observations Completed within expected time frame in 1 year period (1 observation every 6 months. Staff #1 completed initially med practicum on 2/9/23, and Staff #1's annual practicum was dated completed as 3/3/24, which exceeds the "annual" t/timeframe. Staff #1 had Medication Administration Record (MAR) reviews completed on 5/23 and 11/23, and medication administration observations completed on 8/23 and 3/2/24. Staff medication administration training is not being conducted as prescribed by the medication administration training course. (repeat violation 12/8/23) | A staff person who has successfully completed a Department-approved medications administration course, including the course renewal requirements may administer medications, injections, procedures and treatments as specified in § 6400.162 (relating to medication administration). | On 12/3/24, staff was notified she was out of compliance and directed to discontinue passing medications. She was reassigned the medication administration training course on 12/3/24. |
12/30/2024
| Implemented |
| 6400.181(f) | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. Individual #1's Individual Support Plan (ISP) meeting was 12/13/23 and their annual assessment was sent to the team on 12/6/23. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Annual Assessment was sent to individual's team on 12/6/23. |
12/30/2024
| Implemented |
| 6400.213(1)(i) | Violation is 213(1)(iii): Individual #1's Communication, primary language was not included in their record as this was left blank. There is no dropdown box for the regulation cited. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | The individual¿s face sheet was updated in the individual¿s binder. |
12/09/2024
| Implemented |