| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The bathroom sink and toilet were very dirty with noticeable dried stains all over them. Also, the individual's cloth mattress cover had a very large yellow-brownish stain, appearing to be from urinary incontinence, covering a large portion of it. | Clean and sanitary conditions shall be maintained in the home. | 1. A plan to fix the immediate problem
a. WHO: QLS Management and Staff
b. WHAT: QLS staff will be responsible for ensuring the cleanliness and sanitation of the homes in which they work in. QLS management will be responsible for weekly home inspections. QLS Program Specialists will be responsible for ensuring all issues are addressed promptly.
c. WHEN and HOW: On 1/8/2024 QLS management began conducting weekly unannounced home inspections.
|
02/02/2024
| Not Implemented |
| 6400.80(a) | The outside stairwell that leads to the basement of the home had leaves covering the stairs and piled on the landing in front of the basement door. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | 1. A plan to fix the immediate problem.
a. WHO: QLS Management, Maintenance and Staff
b. WHAT: QLS staff will be responsible for ensuring that walkways are free of hazards. QLS management will be responsible for weekly home inspections to ensure compliance with this regulation. QLS Program Specialists will be responsible for ensuring all issues within this regulation are addressed promptly.
c. WHEN and HOW: On 1/8/2024 QLS management began conducting weekly unannounced home inspections.
|
02/02/2024
| Not Implemented |
| 6400.82(f) | At the time of the inspection on 1/3/24, there was no toilet paper in the bathroom. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | 1. A plan to fix the immediate problem
a. WHO: QLS Management and Staff
b. WHAT: QLS staff will be responsible for ensuring that all bathrooms have toilet paper, paper towels and soap. QLS management will be responsible for weekly home inspections. QLS Program Specialists will be responsible for ensuring all issues are addressed promptly.
c. WHEN and HOW: On 1/8/2024 QLS management began conducting weekly unannounced home inspections.
|
02/02/2024
| Implemented |
| 6400.144 | At the time of the inspection on 1/3/24, there were no medications available at the home, including PRN's, due to it being an agency wide "medication change over" day. | 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.
| 1. A plan to fix the immediate problem.
a. WHO: QLS Management and Staff
b. WHAT: QLS Management will ensure that all PRN medications are always available in the home to the individuals. QLS staff will audit and report PRN medication needs.
c. WHEN and HOW: Effective 2/1/2024 all PRN medications will be audited by staff members in the homes weekly and reported back to the Medical Coordinator by Tuesdays at noon of any medications that are low, or close to expiration.
|
02/02/2024
| Implemented |
| 6400.214(b) | At the time of the inspection on 1/4/24, the current ISP and assessment were not available at the home. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| 1. A plan to fix the immediate problem.
a. WHO: QLS Management
b. WHAT: QLS Management will ensure that the staff have access to the most recent assessment, physical, ISP, Behavior Support Plan and any other pertinent information specific to the individual being served
c. WHEN and HOW: QLS Program Specialist, Medical Coordinator and Behavior Specialist will ensure that all records are kept in digital and paper form in the homes for the staff by 2/1/2024.
|
02/05/2024
| Not Implemented |