| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | Individual #1 purchased items that were not for their benefit and should have been provided as part of the Room and Board contract. These items are bath towels for $15.48 purchased on 10/27/24, Oxiclean for $5.98 purchased on 10/03/24, and bodywash for $15.84 purchased on 09/21/24. | Individual funds and property shall be used for the individual's benefit. | All supervisors and Program Specialists were retrained on audits and room and board regulations. All individuals must be reimbursed for all necessities that must be covered through the room and board regulations. All receipts must be analyzed, and the individual must be paid back for the items bought by 6/1/2015. Attached are supporting documents that the individual was reimbursed. |
06/01/2025
| Implemented |
| 6400.22(d)(1) | (repeat from 05/20/24 inspection) Individual #1's "large" account financial ledger is not up to date or correct. The ending balance for October 2024 was $458 and starting balance for November 2024 was $338. This is a discrepancy of $120. The provider indicated the error was previously found and corrected however they did not have sufficient documentation of the error that was found and how it was corrected. | 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. | All ledgers were reassessed for accuracy and discrepancies. Audits were completed and the ledgers were updated ensure money is all accounted for. |
05/19/2025
| Implemented |
| 6400.144 | Individual #1 saw an internal medicine doctor on 02/21/25 for back pain. The doctor noted a possible pulled muscle and recommended to take Tylenol for discomfort. The individual has a standing order to take Tylenol as needed for pain. The corresponding February 2025 Medication Administration Record indicates that no Tylenol was given to the individual for back pain as recommended. | 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.
| All supervisors were retrained on the responsibility for ensuring that an Unusual Behavior Observation report and adequate documentation is completed from dr. orders. The UBO ensures medications, and any treatments are offered to the individual. If a medication/treatment is prescribed as needed, it will be added to the Medication Administration Record. It will also be documented on the UBO if they refuse and were offered the treatment/medication. |
05/19/2025
| Implemented |
| 6400.181(e)(1) | Individual #1's 03/21/25 Annual Assessment does not indicate Individual #1's "preferences". | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | All Program Specialists are to ensure all sections are in the initial and annual assessments. The template for the assessment was updated and distributed to each Program Specialist. They are to audit this during the these processes. This also should be evaluated twice a year by an admin team during the LII process to ensure compliance. |
06/01/2025
| Implemented |
| 6400.211(b)(3) | (repeat from 05/20/24 inspection) Individual #1's Emergency Medical Consent is listed as Individual #1; however, the record also notes Individual #1's sister as medical power of attorney and representative payee. The sister's name, address, and telephone number are not listed in the record. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.
| The Medical Consent form was updated to reflect the medical power attorney and mother as guardian in ISP and assessment. All materials and training is attached. |
05/19/2025
| Implemented |
| 6400.166(a)(2) | The Medication Administration Record (MAR) from June 2024 through May 2025 indicates that all of individual #1's medications are prescribed by their primary physician. There is evidence elsewhere in the record that individual #1's psychiatrist is the prescriber of the following medications: Lithium Carbonate, Lamotrigine, Quetiapine Fumarate, Trazodone, and Fluoxetine. Furthermore, the medication packets at the home indicate a different prescriber for each of the following medications: Docusate Sodium and Vitamin C tablet. Since the individual has more than one prescribing doctor, each medication listed on the MAR should indicate the prescriber. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | The residential supervisors must ensure all MARs show adequate representation of prescribing doctors or specific medications. |
05/19/2025
| Implemented |