| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Individual #1's June 2024 Financial Tracking lists a starting balance of $78.66. On 6/3/2024 a receipt is listed for $14.66 at Teriyaki Madness. The balance after this transaction is recorded as $64.37. The balance is incorrect. The correct balance after this transaction should be $64.00. This incorrect balance carried forward for the rest of the month into the following months. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | 6400.22(d)1 The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. - At the time of inspection Individual #1's June 2024 Financial Tracking lists a starting balance of $78.66. On 6/3/2024 a receipt is listed for $14.66 at Teriyaki Madness. The balance after this transaction is recorded as $64.37. The balance is incorrect. The correct balance after this transaction should be $64.00. This incorrect balance carried forward for the rest of the month into the following months.
1. The balance was corrected including subsequent months immediately
2. All staff will be trained on 6400.2(d) and sign off by 12-31-24 |
12/31/2024
| Implemented |
| 6400.62(a) | At the time of the inspection, the following poisonous materials that stated "contact Poison Control" were found unlocked in the laundry room: 4 bottles of ZEP cleaner, Raid Ant Killer, Goo Gone, and Ortho Home Defense. | Poisonous materials shall be kept locked or made inaccessible to individuals. | 6400.62(a) Poisonous materials shall be kept locked or made inaccessible to individuals. - At the time of the inspection, the following poisonous materials that stated "contact Poison Control" were found unlocked in the laundry room: 4 bottles of ZEP cleaner, Raid Ant Killer, Goo Gone, and Ortho Home Defense.
1. A poisonous materials were locked immediately
2. All staff will be trained on regulation 6400.62(a) and sign off by 12-31-24 |
12/31/2024
| Implemented |
| 6400.181(e)(2) | Upon review of Individual #1's financial logs it was discovered that money is being spent at Tommy's Express Wash. $10 purchase at Tommy's occurred on 6/7/24, 6/27/24, 8/2/24, 8/9/24, 8/30/24. Tommy's Express Wash is a car wash. After discussion with Staff #1 it was confirmed that Individual #1 chooses and likes to utilize the automatic car wash to wash the company vehicle. This is a preferred activity for them. Due to the Individual utilizing their personal funds to wash a company vehicle, this specific information should be documented in the assessment accordingly. | The assessment must include the following information: The likes, dislikes and interest of the individual. | 6400.181(e) (2) The assessment must include the following information: The likes, dislikes and interest of the individual. Upon review of Individual #1's financial logs it was discovered that money is being spent at 's Express Wash. $10 purchase 's occurred on 6/7/24, 6/27/24, 8/2/24, 8/9/24, 8/30/24.'s Express Wash is a car wash. After discussion with Staff #1 it was confirmed that Individual #1 chooses and likes to utilize the automatic car wash to wash the company vehicle. This is a preferred activity for them. Due to the Individual utilizing their personal funds to wash a company vehicle, this specific information should be documented in the assessment accordingly.
1. Under likes and dislikes of the individual, going to the car wash due to sensory needs was put into the assessment.
2. All staff will be trained on 6400.181(e) (2) and sign off by 12-31-24 |
12/31/2024
| Implemented |
| 6400.166(a)(11) | Individual #1's August 2024 Medication Administration Record (MAR) records that they are prescribed Triamcinolone 0.1% cream as needed. There is no diagnosis or purpose of the medication recorded. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | 6400.166(a)(11) A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. At the time of inspection Individual #1's August 2024 Medication Administration Record (MAR) records that they are prescribed Triamcinolone 0.1% cream as needed. There is no diagnosis or purpose of the medication recorded.
1. The pharmacy was contacted to update the mediation to include diagnosis for the Triamcinolone cream as rash
2. All staff will be trained on 6400.166(a)(11) and sign off by 12-31-24
3. All other homes were checked to ensure compliance and were found to be within compliance. |
12/31/2024
| Implemented |
| 6400.166(a)(13) | Individual #1's July 2024 Medication Administration Record (MAR) shows that the individual was administered Fluticasone 50mcg, Montelukast 10mg, and Vitafusion Fiber gummies at 9am on 7/9/24. Only the initials of the staff (SA) were listed as administering the medications. There was no staff name on the MARs that matched SA. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | 6400.166(a)(13) A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. - At the time of inspection Individual #1's July 2024 Medication Administration Record (MAR) shows that the individual was administered Fluticasone 50mcg, Montelukast 10mg, and Vitafusion Fiber gummies at 9am on 7/9/24. Only the initials of the staff (SA) were listed as administering the medications. There was no staff name on the MARs that matched SA.
1. All staff will be trained on how to properly initial the MARS and signature sheet by 10/31/24.
2. All staff will be trained on 6400.166(a)(13) and sign off by 12-31-24
3. All other homes were checked to ensure compliance and were found to be within compliance. |
12/31/2024
| Implemented |
| 6400.182(c) | Upon review of Individual #1's financial logs it was discovered that money is being spent at Tommy's Express Wash. $10 purchase at Tommy's occurred on 6/7/24, 6/27/24, 8/2/24, 8/9/24, 8/30/24. Tommy's Express Wash is a car wash. After discussion with Staff #1 it was confirmed that Individual #1 chooses and likes to utilize the automatic car wash to wash the company vehicle. This is a preferred activity for them, and the Individual plan was not revised when these needs/wants were discovered. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | 6400.182(c) The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. ¿ At the time of inspection Individual #1's financial logs it was discovered that money is being spent at Tommy's Express Wash. $10 purchase at Tommy's occurred on 6/7/24, 6/27/24, 8/2/24, 8/9/24, 8/30/24. Tommy's Express Wash is a car wash. After discussion with Staff #1 it was confirmed that Individual #1 chooses and likes to utilize the automatic car wash to wash the company vehicle. This is a preferred activity for them, and the Individual plan was not revised when these needs/wants were discovered.
1. Under likes and dislikes of the individual, going to the car wash due to sensory needs was put into the assessment.
2. All staff will be trained on 6400.182(c) and sign off by 12-31-24 |
12/31/2024
| Implemented |
| 6400.195(b) | Individual #1's current Behavioral Support Plan dated 7/24/24 states that they have a PRN protocol for medications to be administered when displaying precursors of self-injurious behavior and/or aggression. Upon reviewing MARs, assessment, ISP and speaking with staff it is determined that Individual does NOT utilize PRN medications for self-injurious behaviors and/or aggression. The plan was not reviewed and revised by the human rights team in accordance with the Individual's needs. Additionally, the Behavioral Support Plan states that the Individual's date of admission is 11/01/2020, however their actual date of admission is 5/2021. Lastly, the Behavior Restrictive Support Plan is signed by the behavior specialist and Individual #1. However, the top portion references a different individual entirely, stating "DJ signature below is (his) agreement with this plan. It recommended that the agency practices not utilizing the 'copy & paste' feature to ensure that each plan and protocol is specific to the individual. | The behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews. | 6400.195(b) The behavior support component of the individual plan shall be reviewed and revised as necessary by the human rights team, according to the time frame established by the team, not to exceed 6 months between reviews. At the time of inspection Individual #1's current Behavioral Support Plan dated 7/24/24 states that they have a PRN protocol for medications to be administered when displaying precursors of self-injurious behavior and/or aggression. Upon reviewing MARs, assessment, ISP and speaking with staff it is determined that Individual does NOT utilize PRN medications for self-injurious behaviors and/or aggression. The plan was not reviewed and revised by the human rights team in accordance with the Individual's needs. Additionally, the Behavioral Support Plan states that the Individual's date of admission is 11/01/2020, however their actual date of admission is 5/2021. Lastly, the Behavior Restrictive Support Plan is signed by the behavior specialist and Individual #1. However, the top portion references a different individual entirely, stating "DJ signature below is (his) agreement with this plan. It recommended that the agency practices not utilizing the 'copy & paste' feature to ensure that each plan and protocol is specific to the individual.
1. The Behavioral Support Plan was immediately corrected, and the PRN protocol was removed. The admission date was corrected. The signature page of the Behavioral Support plan was corrected to include the appropriate individual¿s initials and was resigned by the Behavioral Specialist and the parent/guardian.
2. All staff will be trained on regulation 6400.195 (b) and sign off by 12-31-24 |
12/31/2024
| Implemented |
| 6400.213(1)(i) | Individual #1's admission date listed on their member demographics page states 5/3/2021. The admission date listed in in the current assessment (7/3/24) states in two separate places that the date of admission was 5/9/2021. The date of admission is needs to be accurate. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | 6400.213(1)(i) Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. At the time of inspection Individual #1's admission date listed on their member demographics page states 5/3/2021. The admission date listed in in the current assessment (7/3/24) states in two separate places that the date of admission was 5/9/2021. The date of admission is needs to be accurate.
1. The admission date in the assessment 7/3/24 was immediately corrected to include the correct admission date.
2. All staff will be trained on 6400.213 (1)(i) and sign off by 12/31/24. |
12/31/2024
| Implemented |