| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.72(a) | One of the windows in the home's sunroom lacked a window screen. There was no window screen within the home that could be securely placed into the window frame should the window be open and in use. As such, this window was incapable of being securely screened. | Windows, including windows in doors, shall be securely screened when windows or doors are open. | A window screen has been placed in the window. |
04/19/2024
| Implemented |
| 6400.72(b) | The pneumatic closer of the rear storm door in the home's covered back patio was detached from the storm door, leaving the door in disrepair. | Screens, windows and doors shall be in good repair. | The door has been removed as it is an open air porch with no need for a door. |
04/19/2024
| Implemented |
| 6400.112(e) | Fire Drill records for this location show that the 05/18/2023 fire drill was the only fire drill held during sleeping hours from March 2023 through March 2024. Fire Drills have not been held during sleeping hours at least every 6 months at this location as required. | A fire drill shall be held during sleeping hours at least every 6 months. | The agency has created a tracking sheet for the Residential Directors use throughout the calendar year to address and meet the Asleep designated Fire Drills to fall within the 6 months requirement for frequency. This will ensure the frequency is maintained moving forward in this home and all others operated by the agency. |
04/19/2024
| Implemented |
| 6400.141(a) | Individual #2's two most recent physical examinations occurred on 07/31/2023 and 04/21/2022. The interim between these two physical examinations exceeds the annual requirement. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Agency has developed a Tracker Sheet for Residential Directors use for each home that will serve as tracking for full and timely documentation such as Medical Appointments and completion of vital information. |
04/19/2024
| Implemented |
| 6400.141(c)(7) | The only record of a gynecological examination found within Individual #2's Individual Record was dated 03/06/2024. As there was no previous gynecological examination found within the record, it could not be substantiated that the individual received such an examination annually as required. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | The agency Representative reached out to the St. Luke's Portal to retrieve the "Appointment Notes" which describe care provided by the GYN on 6/30/2023. Previous to this appointment the individual received care on 7/12/2022. The individual does see the GYN for Depo injections as indicated on the 2/23/2024 visit form. ECR has developed a Medical Visit Form with the Title GYN to support the documentation of services performed by the GYN in conjunction with the electronic notes. |
04/19/2024
| Implemented |
| 6400.141(c)(13) | Individual #2's physical examination, dated 07/31/2023, did not note the presence or absence of allergies or contraindicated medications. As the corresponding item on the physical form was left blank by the medical professional completing the form, it could not be determined whether the individual had any allergies or whether any medications were contraindicated for the individual. | The physical examination shall include: Allergies or contraindicated medications. | The agency Representative reached out to the St. Luke's Portal for the electronic information complete by the medical provider at the time of the appointment and has placed that information on the Individual's record to ensure that the required areas are documented in the record. |
04/19/2024
| Implemented |
| 6400.141(c)(14) | Individual #2's physical examination, dated 07/31/2023, did not note medical information pertinent to diagnosis and treatment in case of an emergency. The corresponding item on the physical form was left blank by the medical professional completing the form. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The agency Representative reached out to the St. Luke's Portal for the electronic information complete by the medical provider at the time of the appointment and has placed that information on the Individual's record to ensure that the required areas are documented in the record. |
04/19/2024
| Implemented |
| 6400.142(f) | There was no written dental hygiene plan on file for Individual #2 in the Individual Record. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | The agency Representative copied the Dental Hygiene Plan from the House Record and has placed that copy in the Office Record. A new Dental Hygiene Format plan has been created and we are requesting the Support's Coordinators to include this information in the ISP as well. |
04/19/2024
| Implemented |
| 6400.144 | Per the March 2024 Medication Administration Record (MAR), Individual #2 was prescribed a Pro Re Nata (PRN) psychotropic medication, Hydroxyz HCL Tab 25mg, with instructions to "Take 1 Tablet by mouth Twice a Day as needed." Although not listed on the MAR entry for this medication, documentation elsewhere in the Individual Record noted that this medication was prescribed for the psychiatric diagnosis of "anxiety." The administration instructions for this restrictive intervention were deficient in several areas:
1. There were no written instructions by a physician or medical practitioner listing the individual's specific symptoms of "anxiety" that would warrant the use of a PRN psychotropic medication included in the physician's prescription of the medication.
2. Prescribed directions on the pharmacy label did not include frequency (dose and allowable rate of recurrence of dosage) for administration of the PRN.
3. There was no evidence of a formalized protocol which established that the Chief Executive Officer (CEO) or a specific agency employee designated by the CEO must be called to give prior authorization to administer the medication each time the medication is administered to the individual and that this authorization must be documented in the MAR.
As an administration procedure encompassing the above requirements had not been established by the provider for this PRN psychotropic medication, appropriate pharmaceutical services were not planned for the individual by the provider. | 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 agency Representative reached out to the Prescribing Physician to correct the label of the medication to include "Anxiety". The individual has a history of anxiety as evidenced by yelling, crying at times with family and sometime ago with her current roommate. This behavior has not been evident and the PRN has not been utilized. The Prescribing Physician has been asked to discontinue the medication. PRN Protocol has been put in place until the discontinue order from the prescriber is received. |
04/19/2024
| Implemented |
| 6400.165(g) | Individual #2 is prescribed psychotropic medications for the treatment of a psychiatric condition. Per physician encounter forms in the Individual Record, Individual #2's four most recent psychiatric appointments occurred on 01/30/2024, 08/18/2023, 06/13/2023, and 05/02/2023. The interim between the 01/30/2024 and 08/18/2023 appointments is in excess of 3 months. This individual's psychotropic medications were not reviewed at least once every 3 months by a licensed physician as required. In addition, the physician encounter forms associated with these visits did not include the reason for prescribing the medication as required. The 01/30/2024 physician encounter form also lacked documentation of the need to continue the prescribed medications. | 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. | The agency has reached out to the Prescribing Physician to ensure that every area of the requirements is documented on the Medication Review's. ECR will ensure that the appointments for the Medication Reviews are made in a timely fashion of 3 months or less and that the documents are retained in the Individual's office record per the regulations. |
04/19/2024
| Implemented |
| 6400.166(a)(11) | Individual #2 is prescribed Hydroxyz HCL Tab 25mg "Take 1 Tablet by mouth Twice a Day as needed." There was no diagnosis listed for this medication in the March 2024 Medication Administration Record (MAR) or on the medication's pharmacy label. | 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. | The agency Representative made correction to the MAR to include the diagnosis of Anxiety, the prescriber has included the diagnosis on the label of the medication. |
04/19/2024
| Implemented |
| 6400.181(f) | There was no documentary evidence to show that the Program Specialist provided Individual #2's Individual Assessment to the members of the Individual Plan Team at least 30 calendar days prior to the Individual Plan Meeting on 01/12/2024. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | The agency has placed a checklist on the last page of the Assessment along with the formal Transmittal Letter previously used for proof of Assessment copies made available to designated persons per the regulatory requirements. |
04/19/2024
| Implemented |
| 6400.183(c) | Individual #2's Individual Record did not contain a record of the persons who participated in the Individual Plan meeting on 01/12/2024. | The list of persons who participated in the individual plan meeting shall be kept. | The agency Representative has reached out to the Supports Coordinator to obtain a copy of the ISP Signature Sheet for the individuals record. The agency will retain ISP Signature sheets for every individual moving forward. |
04/19/2024
| Implemented |