| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.70(d) | The first aid did not contain antiseptic in the first aid area which was corrected during inspection, the first aid kit in the common area did not contain antiseptic. | First aid kits shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer or other temperature gauging equipment, tweezers, tape and scissors. | Antiseptic wipes were placed in each first-aid kit. Attachments #23 and #24 |
02/09/2024
| Implemented |
| 2380.111(a) | Individual One's most current physical was dated 8/4/22 which is out of the regulatory timeframe. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual #1's current annual physical was obtained and placed in the record. Attachment #17. |
02/07/2024
| Implemented |
| 2380.111(c)(5) | No current TB Screening was located in Individual Three's binder.
(TB) Tuberculin skin testing for Individual Six was not completed every 2 years, last test with a negative result was completed 07/13/2021 and not completed again until 08/08/2023.
(TB) Tuberculin skin testing for Individual Seven is not being completed every 2 years, last test with a negative result was completed on 10/21/2019 and not completed again until 01/09/2023. | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted. | Current TB screening was obtained and placed in the record. for Individuals #3, #6, and #7. Attachments #6, #10, and #15. |
05/09/2024
| Implemented |
| 2380.111(c)(7) | Individual One's annual physical dated 8/4/22 did not include health maintenance assessment. The area on the form was left blank.
Individual Two's annual physical dated 10/21/22 did not indicate health maintenance needs. The area on the form was left blank. | 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. | Updated physical's were received and placed in the record for Individual #1 and Individual #2. Attachments #3 and #17. |
02/08/2024
| Implemented |
| 2380.111(c)(10) | Individual One's annual physical dated 8/4/22 did not include information pertinent to diagnosis in case of emergency. The area on the form was left blank.
Individual Two's annual physical dated 10/21/22 did not indicate health maintenance needs. The area on the form was left blank.
The annual physical for Individual Five dated 6/30/23 did not include Information pertinent to diagnosis and treatment to diagnosis in case of emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Updated physical was received and placed in the record for Individual #1 and Individual #2. Attachments #3 and #17. |
02/08/2024
| Implemented |
| 2380.113(a) | Staff One's most recent physical was completed on 03/23/22, with the previous physical completed on 1/27/20. This dateThe Staff Two had a QuantiFERON-TB Gold Plus TB test completed on 7/6/22 but there is no record of a corresponding physical exam on that date. Staff Two's prior physical was completed on 8/19/2020. The physical was not completed until 1/26/2023. range exceeds the 2-year requirement by 1 month and 24 days. | 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 persons, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | Updated physicals were received for Staff #1 and Staff #2 and place in their file. Attachments #27 and #28. |
02/14/2024
| Implemented |
| 2380.173(1)(ii) | The record of Individual Six did not include identifying marks, this portion was left blank. | Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks. | Consumer information sheet was updated to include identifying marks. Attachment #8. |
02/01/2024
| Implemented |
| 2380.181(a) | Individual One's file did not contain an assessment.
Most recent Annual Assessment on file for Individual Eight was from 2019 which is well beyond that annual requirement.
The most recent annual assessment for Individual Four dated 9/4/23 is nearly identical to the annual assessment from a year prior.
The 2023 assessment still includes information that is not longer accurate. For example '22 and '23 both say he has lived in his CLA for 3 years, and including the same information about a vacation that occurred 'that year'.
The individual Six's progress over the last 365 calendar days and current level is identical from 2021 thru 2023. A clearer progress of the individual in the areas of health, motor and communication skills, and personal adjustment should be updated. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | Revised assessments were completed and disseminated to the corresponding SCO's for Individuals #1, #4, and #8. Attachments #1, #14, and #20. |
02/14/2024
| Implemented |
| 2380.181(e)(10) | The lifetime medical history included on Individual Fours' most recent assessment was not current. For example the most recent TB test on the document is from 2017. | The assessment must include the following information: A lifetime medical history. | Revised lifetime medical was updated and placed in the record and disseminated to SCO for Individual #1. |
02/05/2024
| Implemented |
| 2380.156(c) | CEO Trainings: Training Source was not listed on any of the trainings. | Documentation of the training provided, including the staff persons trained, dates of training, description of training and training source, shall be kept. | Updated CEO training record received with corresponding training source and placed in training file. Attachment #16. |
02/01/2024
| Implemented |