| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | Individual #1's funds were used to purchase health and beauty products, which are to be included in room and board. | Individual funds and property shall be used for the individual's benefit. | An EIM and investigation was initiated on 3/12/24, regarding misuse of funds due to individual #1 purchasing health and beauty products. An agency reimbursement was completed on 3/20/24 by Program Specialist to reimburse individual funds for the purchase of health and beauty products purchased on various dates throughout the year and totaling $57.61 (See attachment #9a). |
05/30/2024
| Implemented |
| 6400.22(d)(1) | Individual #1's financial record was not current and up to date. Beginning in October 2023, numerous mathematical errors occurred and were not rectified. | 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. | Financial records for Individual were reviewed by DCQM and it was calculated that the individual was missing a total of 19 cents over the time frame of October 2023's financial ledger through the current financial ledger. A request for reimbursement was completed for the 19 cents by DCQM (see attachment) on 3/19/24. The 19 cents were reimbursed to the individual's March financial ledger on 3/21/24 by Program Supervisor. (see attachment #10a). |
05/30/2024
| Implemented |
| 6400.22(e)(1) | Individual #1 had multiple checks deposited into their petty cash that were not fully documented on the individual's cash ledgers. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: A separate record of financial resources, including the dates and amounts of deposits and withdrawals. | In-house financial records for the individual were reviewed by DCQM on 3/21/24 and specific amounts from the cashed checks were added, in those areas missing deposit amounts. This information was added as a late entry (See attachments #11a, #11b and #11c). |
05/30/2024
| Implemented |
| 6400.43(b)(1) | On 12/11/23 an "agreement" was signed between Individual #1 and Staff #1 agreeing that CRS can terminate placement effective immediately. This directly contradicts 6100 regulations that require a 45-day discharge notice. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | A new service agreement was created by agency CEO on 3/22/24, which was reviewed with individual #1 by Program Specialist on 3/22/24. (See attachment #12 includes: 8 pages) This newly created service agreement does not contain language stating that CRS can terminate placement effective immediately and does not directly contradict 6100 regulations. |
04/15/2024
| Implemented |
| 6400.106 | The home opened in May 2023 and has yet to have a furnace inspection or cleaning. | Furnaces shall be inspected and cleaned at least annually by a professional furnace cleaning company. Written documentation of the inspection and cleaning shall be kept.
| Home was opened in May 2023 and furnace was inspected and cleaned at this location on 3/13/24 (See attachment #13a). Furnace was not originally inspected and cleaned at this location due to the home being newly built. |
04/15/2024
| Implemented |
| 6400.141(b) | The examination was completed on 8/21/23. The physician did not sign and date the form until 9/1/23. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Although the physical was signed for 09/01/2023, an after-visit printout, as well as physician summary, was received on 03/21/2024, indicating the physical was completed within the annual time frame on 08/21/2023, as indicated by the physician signature and date on his summary. This summary was placed with the individual #1's annual physical form on 08/21/2023. An appointment follow-up reminder was added to Individual#1's digital appointment calendar for his 08/21/2024, scheduled annual physical to RSWs, residential supervisor, and residential specialist to retrieve the annual physical form the day of the appointment and ensure it is signed and dated by the physician. |
04/15/2024
| Implemented |
| 6400.141(c)(4) | Individual #1 has not had a hearing examination. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | On the physical form dated 08/21/2023, for individual #1, there is no indication if a hearing screening was completed. On 03/21/2024, an appointment was made for individual #1 at the Primary Care Physician for a hearing screening and any further recommendations to hearing evaluations, if deemed needed. This appointment is scheduled for 03/28/2024 at 10am, which was upheld (See attachment #15a- 4 pages). |
04/15/2024
| Implemented |
| 6400.181(e)(1) | Individual #1's most recent assessment completed on 5/5/23 does not identify their functional strengths. | The assessment must include the following information: Functional strengths, needs and preferences of the individual. | An addendum was completed for Individual #1 addressing their functional strengths. This addendum was sent to the team on 03/21/2024 (See attachment #16a- 3 pages). |
05/01/2024
| Implemented |
| 6400.181(e)(2) | Individual #1's most recent assessment completed on 5/5/23 does not clearly identify Individual #1's interests. | The assessment must include the following information: The likes, dislikes and interest of the individual. | An addendum was completed for Individual #1 addressing their interests. This addendum was sent to the team on 03/21/2024 (See attachment #17a- 3 pages). |
04/15/2024
| Implemented |
| 6400.167(a)(3) | Individual #1 is prescribed Risperidone to be taken three times a day. 1 tablet at 7:30am. 1 tablet at 3:30pm. 2 Tablets at 9:30pm. For the month of March 2024, Individual #1 has been given two tablets at 7:30am and only 1 tablet at 9:30pm. | Medication errors include the following: Administration of the wrong dose of medication. | Staff contacted Individual #1's prescribing physician on 03/13/2024 for instructions on medication administration; contact was made, and instructions were received (See attachment #17a). An EIM was completed on 03/14/2024. A house training regarding the medication error was conducted on 03/21/2024 and completed 03/23/2024 (See attachment #17b). |
04/15/2024
| Implemented |
| 6400.181(b) | Individual #1 moved to a new home and the assessment was not updated reflecting the changes. | If the program specialist is making a recommendation to revise a service or outcome in the individual plan, the individual shall have an assessment completed as required under this section. | A complete assessment of individual #1's skills was completed to reflect their current abilities and recent changes on 03/25/2024, by the Program Specialist and sent to the team: Individual #1, family, residential program supervisor, RSWs of the group home, supports coordinator, behavior support personnel, and community participation supports (See attachment #18a- 15 pages). Program specialist requested Individual #1 have the updates added to his ISP to reflect his current abilities. |
05/01/2024
| Implemented |
| 6400.186 | Individual #1's ISP documents that the HRT approved physical restraints to be used. There was no restrictive procedure established. | The home shall implement the individual plan, including revisions. | Individual #1 had their BSP plan updated on 10/13/2023 (See attachment #19a- 8 pages). During the inspection, the 10/13/2023 BSP was not available in Individual #1's main file, for it was in the group home. The BSP dated 10/13/2023 reflects that the following restrictions have been discontinued: sharps locked and physical restraints. Individual #1 met criteria for the discontinuation of the restrictive procedures on 10/13/23. SC was contacted 03/27/2024 by program specialist about restrictions being removed from individual #1's ISP to reflect current needs (See attachment #19a- 8 pages). |
04/15/2024
| Implemented |