| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.113(a) | 6400.113(a)Individual #1 was admitted on 5/1/23 and his initial fire drill was not completed until 5/15/23. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | The program specialist will complete a move in day checklist to all house managers/supervisors to ensure that a first day fire drill is conducted with all new individuals. |
02/29/2024
| Implemented |
| 6400.141(c)(11) | 6400.141(c)(11) The annual physical dated 4/26/23 for individual #1 is missing recommended intervals for blood work. | 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. | The program specialist or agency nurse will attach the appointment protocol as a guide for staff and consumers who attend their medical appointments alone as reference guide to ensure that all sections of each physical is completed in its entirety. |
01/26/2024
| Implemented |
| 6400.141(c)(14) | 6400.141(c)(14) The annual physical dated 4/26/23 for individual #1is missing information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The program specialist or agency nurse will attach the appointment protocol as a guide for staff and consumers who attend their medical appointments alone as reference guide to ensure that all sections of each physical are completed in its entirety. |
02/29/2024
| Implemented |
| 6400.141(c)(15) | 6400.141(c)(15) The annual physical dated 4/26/23 for individualc#1 is missing Special instructions for the individual's diet. | The physical examination shall include:Special instructions for the individual's diet. | The program specialist or agency nurse will attach the appointment protocol as a guide for staff and consumers who attend their medical appointments alone as reference to ensure that all sections of each physical are completed in its entirety. |
02/29/2024
| Implemented |
| 6400.151(c)(3) | 151c3 Staff Number 1(physical dated 8/5/22) and 2 (3/30/22 physical exam) doesn't say if they are free from communicable diseases. | The physical examination shall include: A signed statement that the staff person is free of communicable diseases or that the staff person has a communicable disease but is able to work in the home if specific precautions are taken that will prevent the spread of the disease to individuals. | The program specialist or agency nurse will review each psychical form to ensure that the form is completed in its entirety and return the form to the attending physician for updates if information is missing on the form. |
02/29/2024
| Implemented |
| 6400.217 | The JAMI Residences Program Consent to Services form for individual #1 has not been fully completed, with the agencies where health information will be released to left blank on the form. The individual signed the form, which is lacking the necessary information, as well as lacking his initials to approve each entity. There is also no date on the form. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| The program specialist has separated each consent form to identify only one specific title to identify where and whom the individual's information will be shared. |
02/29/2024
| Implemented |
| 6400.32(r) | 6400.32(r)The statement of individual rights for individual #1 is missing wording stating, "The individual has the right to lock his/her bedroom door." | An individual has the right to lock the individual's bedroom door. | The programs specialist has added in the individual rights consent form that all individuals have the right to lock his/her bedroom door and be provided a key or code to keyless pad entry. An extra copy of the key or keyless pass code will remain on site to gain access in case of an emergency. |
02/29/2024
| Implemented |
| 6400.169(d) | The current Medication administration packet was not complete for staff #1 and therefore could not be verified at the time of the inspection if they successfully completed the training. | A record of the training shall be kept, including the person trained, the date, source, name of trainer and documentation that the course was successfully completed. | Provider has began to retrain all employee's in the update version of the medication administration training. Every employee will have their complete training file uploaded into their training file. Provider will also have a random sample of employee files reviewed quarterly. |
03/31/2024
| Implemented |