| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.142(f) | 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. Individual #1 had an agency Dental hygiene plan in their record dated 4/1/23 and 3/27/23 however it only stated that the individual will undergo a dental examination on an annual basis, and that that they will have their own toothbrush which will be replaced as needed. The agency dental hygiene plan does not address dental hygiene and is not specific to each individual's dental hygiene needs. There is no record that Individual #1 had achieved dental hygiene independence and their Individual Support plan dated 7/4/24 noted Individual #1 refuses to brush teeth daily. | 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. | Reviewed dental hygiene plan and implemented new plan to address need. If an Individual refuses oral care additional documentation will be implemented with options and attempts to educate on benefits of good oral hygiene. |
10/15/2024
| Implemented |
| 6400.144 | Individual #1 is prescribed Lorazepam 1 mg, take ½ tablet by mouth three times daily as needed for anxiety max daily amount 1.5 mg. The October 2024 Medication Administration Record (MAR) Individual #1 was administered the medication on 10/6/24. According to the agency, Individual #1 is only administered the medication when they request it. There was no record of a protocol or specific directions in Individual #1's record for the administration of this medication. | 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.
| Written protocol obtained from Provider on 10/17/2024, Mar updated to include protocol. |
10/17/2024
| Implemented |
| 6400.163(h) | Individual #1 is prescribed Lorazepam 1 mg, take ½ tablet by mouth three times daily as needed for anxiety max daily amount 1.5 mg. The pharmacy label on the medication had an expiration date of 8/27/24. The medication remained with the individual's medications and was not disposed of properly. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | 10/7/2024 Medication was disposed. 10/9/2024 Updated medication disposal protocol and distributed to all house supervisors for review. |
10/10/2024
| Implemented |
| 6400.182(c) | Individual #1's Individual Support plan (ISP) plan dated 7/4/24 states under the general health and safety risks that Individual #1 does not manage her own money as she was withdrawing money from the bank without ensuring bills were paid and this led to some overdrafts. Individual #1 also has a history of ordering and charging items in the community without knowing how much money she has to spend. Under the Learning/cognition section of Individual #1's ISP it states Individual #1 requires verbal assistance with money management. Individual #1 tends to make unnecessary purchases and has little understanding of where her money has gone at the end of the day without help from staff. Individual #1's assessment dated 5/21/24 states Individual #1 does not have a complete understanding of money. She at times will make unnecessary purchases with her money and does not understand where her money is at the end of the day. Individual #1 should not have more than $25.00 on her person at a given time. The ISP and assessment do not match. The individual plan shall be revised when an individual's needs change based upon a current assessment. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | Assessment and ISP reviewed, revised assessment emailed 10/15/2024. ISP changes requested on 10/15/2024 to reflect current skill level |
10/15/2024
| Implemented |
| 6400.188(a) | The home shall provide services including assistance, training and support for the acquisition, maintenance or improvement of functional skills, personal needs, communication, and personal adjustment. According to Individual #1's Individual Support plan dated 7/4/24 it noted that Individual #1 refuses to brush their teeth daily there is no record or documentation that the agency is addressing this behavior or training Individual on the importance of oral hygiene care. | The home shall provide services, including assistance, training and support for the acquisition, maintenance or improvement of functional skills, personal needs, communication and personal adjustment. | Upon review of Individual #1 teeth brushing, Program Specialist reported #1 had finished a teeth brushing goal and was brushing with verbal prompts and Independently. Program Specialist indicated she had failed to revise the assessment and request an update to the ISP. Assessment revised and request to update ISP was made to the SC. |
10/09/2024
| Implemented |