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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(b) | At the time of the inspection, there was a gold ball size amount of lint in the lint trap of the dryer. | Floors, walls, ceilings and other surfaces shall be free of hazards. | The lint was immediately removed from the dryer lint trap on 10-2-24.
Stickers were purchased for all homes that state ¿Please clean lint trap before and after each use. These were given to all managers on 10-9-24 to place on all dryers.
The Director of Residential Services provided written education/retraining to all staff, including Program Specialists, Program Managers, Program Supervisors and Direct Care Professionals on 10-11-24 regarding regulation 67(b) that specifies that floors, walls, ceilings and other surfaces shall be free of hazards.
The Director of Residential services provided verbal retraining to all Program Specialists, Program Managers and Program Supervisors on 10-9-24 in an in-person department management meeting regarding regulation 67(b). |
10/17/2024
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.144 | Individual #1was discharged from the hospital with the following notes: ED provider notes from Adam Batog, DO at 8/30/2024 2:32pm states "Please empty Foley catheter bag as it becomes full throughout the day. Individual #1 then went to an appointment for agitation and the following note was documented: ED Provider note from Cynthia Gessler, DO at 8/31/2024 7:10am states "This RN assisted the pt to a bedside commode and identified the patient's urinary catheter was wrapped around the stat lock, causing tension on the urinary catheter. This RN readjusted the urinary catheter which allowed a small amount of yellow urine to drain from the catheter". Staff #15 stated "during interview that no training was provided on the discharge notes since it was pretty elementary." Staff should be provided with training on any new discharge instructions. | 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.
| The Director of Residential Services provided written education/retraining to Program Specialists on 10-31-24 regarding regulation 144 and the home implementing the individual plan, including revisions.
The Director of Residential services will provide verbal retraining to the Associate Directors and Program Supervisors at the next in person management meeting scheduled for 11-13-24. The verbal retraining will include a discussion regarding regulation 144 and specifically review of the after visit summaries, training that needs to occur following a medical appointment, and ensuring 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.
Staff #15 has been retrained by the Director of Residential Services in regard to training not being provided on the discharge notes since it was pretty elementary. This occurred on 10-24-24. |
11/01/2024
| Implemented |
| 6400.186 | Individual #1's Health Assessment dated 9/11/2024 states "individual #1 is on a pureed diet with thin liquids due to mild to moderate oral dysphagia. All food including fruits and vegetables should be pureed. Low fat, low cholesterol, and low sodium diet. The IDD Annual Assessment dated 3/8/2024 states "individual #1 is on a mechanical soft diet with thin liquids due to mild to moderate oral dysphagia. No bread, crackers, cookies, or cake (only cake mixed with milk). All fruits and vegetables should be chopped. Low fat, low cholesterol, and low sodium diet. The ISP dated 7/25/2024 states "individual #1's food should be mechanical soft, his meat ground, his fruit and vegetables cut into small pieces. He should not be eating crackers, cookies, or cake (cake can be consumed if mixed with milk). He follows a low fat, low cholesterol, and low sodium diet. | The home shall implement the individual plan, including revisions. | The Director of Residential Services provided written education/retraining to Program Specialists on 10-31-24 regarding regulation 186 and the home implementing the individual plan, including revisions.
The Director of Residential services will provide verbal retraining to the Associate Directors and Program Supervisors at the next in person management meeting scheduled for 11-13-24. The verbal retraining will include a discussion regarding regulation 186 specifically reviewing the requirements for implementing the individual plan, including revisions. |
11/01/2024
| Implemented |
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