| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(7) | Individual #1 had a gynecological examination completed on 1/16/24, and again on 2/25/25. | 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. | Actions immediately taken: What do we do right now?
¿ The person previously responsible for ensuring the Gynecological examinations were conducted in accordance with Chapter 6400 have been relieved of their duties permanently.
¿ The Nurse Specialist is now responsible for reviewing and ensuring compliance with all medical appointments. (Annual Gynecological/ Breast examinations)
¿ The Nurse Specialist is currently reviewing all (19) individuals' specialty medical appointments ( Mammogram, Gyne, and Prostate Exams) to ensure they comply with the Chapter 6400 regulations. Health Care Provider recommendations. Using the LIS to document the findings. These reviews will be completed on or before August 15th 2025.
¿ We have added an appointment reminder to schedule Individual #1 a 2026 Gynecological examination to the outlook calendar. We have included a screenshot of the outlook calendar for your reference.
¿ This will help avoid missed appointments in the future. |
08/20/2025
| Implemented |
| 6400.141(c)(8) | Individual #1's last annual mammogram was completed on 1/16/24. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | Actions immediately taken: What do we do right now?
¿ The person previously responsible for ensuring the Mammograms were conducted in accordance with Chapter 6400 have been relieved of their duties permanently.
¿ The Nurse Specialist is now responsible for reviewing and ensuring compliance with all medical appointments. ( Mammogram)
¿ The Nurse Specialist is currently reviewing all (19) individuals' specialty medical appointments ( Mammogram, Gyne, and Prostate Exams) to ensure they comply with the Chapter 6400 regulations. Health Care Provider recommendations. Using the LIS to document the findings.
¿ To ensure ongoing compliance. Individual #1 mammograms were on 04-04-24 and 04-25-25. Which resulted in a violation.
¿ We have added an appointment reminder to schedule Individual# 1 a 2026 mammogram to the outlook calendar. Due to prescriptions for mammograms being annually. Imaging scheduling is only available until the end of this year.* We have included a screenshot of the outlook calendar for your reference. |
08/01/2025
| Implemented |
| 6400.34(a) | Individual #1 was informed of and explained their individual rights and the process to report a rights violation on 11/01/23, and again on 12/11/24. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | Actions immediately taken: What do we do right now?
¿ The person previously responsible for ensuring the Individuals rights were conducted in accordance with Chapter 6400.34 have been relieved of their duties permanently.
¿ The Chief Executive Assistant is now responsible for ensuring the Individuals rights are explained and the individual is informed.
¿ A review of all of the Individual¿s Rights Statements were conducted.
¿ To ensure all Individuals are informed of their rights. A re-training was conducted on July 21st 2025. * Please see enclosed the attachment for Individual #1. To ensure compliance all our Residential Individuals were informed. * One of our individuals is on vacation and another is currently hospitalized. When they return, they will be informed of their rights also. |
07/31/2025
| Implemented |
| 6400.166(b) | Individual #1 is prescribed Ammonium Lactate Cream 12%, apply topically to feet daily for dry skin. Individual #1's July 2025 Medication Administration Record was not initialed by the staff member who administered the medication on 7/5/25 at 8:00 p.m. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Actions immediately taken: What do we do right now?
¿ Immediately. After being made aware. the Nurse Specialist looked into the matter and confirmed the medication was given by our staff member.
¿ Staff documented on the hard copy Mar which wasn¿t available during the on-site inspection. * Please see attached.
¿ The staff member completed retraining which included two medication pass observations on July 14, 2025. * Please see attached.
¿ The nurse specialist reviewed all individuals' medication records after being made aware of the above situation.* Please see attached. |
08/15/2025
| Implemented |