| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The rug located in the living room in front of the couch had 9 ½ to 5 inch brown stains. The rug in individual #1's bedroom had three 2 inch circles of mold. | 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 |
| 6400.76(a) | The chair in the living room located beside the tv had 5 ½ to 3 inch brown stains on the arms and seat cushion. The couch beside the chair in the living room had a broken left arm. | Furniture and equipment shall be nonhazardous, clean and sturdy. | 1. A plan to fix the immediate problem.
a. WHO: QLS Management, Maintenance and Staff
b. WHAT: QLS staff will be responsible for that all furniture is nonhazardous, clean and sturdy in the homes they work in. 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 are addressed promptly.
c. WHEN and HOW: On 1/8/2024 QLS management began conducting weekly unannounced home inspections. QLS Staff immediately report any issues with furniture to the QLS management team. QLS Maintenance will address, repair or replace any items in question. |
02/02/2024
| Implemented |
| 6400.77(b) | At the time of the inspection there was no medical tape in the first aide kit. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | 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 first aid kits are equipped and well maintained with the appropriate items. QLS management will be responsible for weekly home inspections, including a comprehensive inventory check of the first aid kits. 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 |
| 6400.216(b) | At the time of the inspection the staff #1 could not access the individual #1's ISP or assessment. | The individual, and the individual's parent, guardian or advocate, shall have access to the records and to information in the records. If the interdisciplinary team documents that disclosure of specific information constitutes a substantial detriment to the individual or that disclosure of specific information will reveal the identity of another individual or breach the confidentiality of persons who have provided information upon an agreement to maintain their confidentiality, that specific information identified may be withheld. | 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
| Implemented |
| 6400.165(b) | Individual #1 did not have a current order for the following medications: Lithium Carb 450 MG, Clozapine 100mg, and Clozapine 200mg. | A prescription order shall be kept current. | a. WHO: QLS Medical Coordinator
b. WHAT: QLS Medical Coordinator will ensure that all medication records have complete and accurate information along with a physicians order.
c. WHEN and HOW: QLS Medical Coordinator will work with the pharmacy and the eMar System in order to ensure all medication records are accurate and complete by 2/1/2024 including obtaining a physicians order |
02/02/2024
| Implemented |
| 6400.186 | Individual's ISP dated 7/18/23 states a 1500 calorie, low fat, and low cholesterol diet. At the time of the inspection there was 6 iced lattes on the counter each containing 260 calories per bottle. The counter was stacked with chips, cakes, cookies, and pastries. No diet information was being tracked for the individual. | The home shall implement the individual plan, including revisions. | 1. A plan to fix the immediate problem.
a. WHO: QLS Management and Staff
b. WHAT: QLS Program Specialist will ensure that all revisions to the individual plan are made available for staff immediately via the online database and update the individual binder within the home. QLS Program Specialists will monitor that all plans are being implemented. QLS Staff will review any revisions and sign off that they have read and understand them as well as begin implementing the changes.
c. WHEN and HOW: QLS Medical Coordinator will ensure all homes have received training on any and all medically related restrictions, recommendations, practices for each individual. QLS Behavior Specialist will ensure that staff are trained on all behavioral support plans, restrictions, non-restrictive environmental adaptations. QLS Program Specialists will ensure that all staff are trained on the individual plans and are implementing them by conducting weekly audits of documentation in the homes. QLS management will be conducting weekly house inspections to ensure compliance with this regulation.
|
02/02/2024
| Not Implemented |