| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(f) | There was an outdoor trash receptacle located in the yard, against the side of the house, upside down, with the lid off and an old trash bag with debris protruding from it. | Trash outside the home shall be kept in closed receptacles that prevent the penetration of insects and rodents. | All trash receptacles must be with lids to ensure sanitary conditions and to keep the property free and safe from insects and rodents. This trash on the ground was disposed and the lid of the trash can was secured to prevent further issues at the time of the inspection (Attachment #2). |
10/11/2024
| Implemented |
| 6400.67(a) | The painted wall on the closet side of individual #2's room has a significantly large area of scraping damage and requires fixing. There is also a large, patched area on the wall opposite her bed where the television mount was moved that requires fixing as well. | Floors, walls, ceilings and other surfaces shall be in good repair. | All surfaces must be in good repair and tidy sanitary conditions must be present throughout the home to include the resident's bedroom. Work orders to make cosmetic improvements were entered into the facilities system (Attachment #4). |
11/21/2024
| Implemented |
| 6400.82(f) | There was no soap available for use in either of the two bathrooms in the home. | 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. | In order to ensure safe and sanitary conditions that prevent the spread of germs and illness each bathroom must be stocked with soap, toilet paper and paper towels. CADES failed to ensure soap was available in the restrooms causing a health and safety concern. Soap was placed in both bathrooms on 10/14/24 to correct this violation and ensure sanitary conditions in the home. |
10/14/2024
| Implemented |
| 6400.83(b) | Individual #2's ISP recommends adaptive mealtime dishes with a lip on the plate and bowl. No adaptive dishes present in the home. | Special provisions shall be made and adaptive equipment shall be provided, when necessary, to assist individuals in eating at the table. | Individual #2 has had a decline since summer 2024 and is no longer able to self-feed, so a PT/OT consult will need to be scheduled to determine current recommendations.
1) Healthcare Supervisor/Community Nurse has scheduled an appointment with Individual #2's primary care physician to discuss a PT/OT referral for current adaptive equipment recommendations. The soonest appointment available is scheduled for 12/17/24. Target date 12/31/24.
2) Provided PCP provides a PT/OT referral, Healthcare Supervisor/Community Nurse will coordinate PT/OT services. Target date 1/31/25. |
01/31/2025
| Not Implemented |
| 6400.112(f) | The front door was used as the exit for all fire drills for the year from 9/15/2023 through 9/12/2024. Regulation requires that alternate routes shall be used during fire drills. The home has a secondary egress listed in the evacuation plan, but only the primary exit (front door) was used in all the fire drills. | Alternate exit routes shall be used during fire drills. | 1. The Program Manager will ensure the site utilizes the secondary egress for its next fire drill. Target Date 12/31/24.
2. The Assistant Director of Quality Assurance will review all fire drills for the last 3 months to identify any other sites which have used the same egress. If any additional sites are identified, the Assistant Director will direct the Program Manager responsible for the site that they need to utilize an alternate egress during the next fire drill. Target Date 12/31/24. |
12/31/2024
| Not Implemented |
| 6400.144 | Individual #3 did not have any breakthrough seizure medication at the home. Current order reads 'to give before medical appts' and separate order (same medication) "to give for seizures lasting longer than 5 minutes". Lorazepam medication last given on 10/2/24 prior to medical appointment. Individual has history of recent seizures.
Individual #2 had a significant weight loss. Weight log provided by CADES April/2024= 184lbs, July/2024= 178lbs, and August/2024= 164lbs. Data results with a 20-pound weight loss in 4 months, 12-pound weight loss in recent 2 months. No evidence of PCP or nutritional consultation. | 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) Healthcare Supervisor/Community Nurse reordered Individual #3's breakthrough seizure medication, and it is now on site. Target Date 11/20/24.
2) Healthcare Supervisor/Community Nurse will audit PRN medications for other individuals at the site to ensure other residents medications are not expired and available. Target date 12/1/24.
3) Healthcare Supervisor/Community Nurse has scheduled an appointment with Individual #2's primary care physician to discuss weight loss. The soonest appointment available is scheduled for 12/17/24. Target date 12/31/24. |
12/31/2024
| Not Implemented |
| 6400.32(c) | Individual #2 had Significant weight loss. Weight log provided by CADES April/2024= 184lbs, July/2024= 178lbs, and August/2024= 164lbs. Data results with a 20-pound weight loss in 4 months, 12-pound weight loss in recent 2 months. No evidence of PCP or nutritional consultation | An individual may not be abused, neglected, mistreated, exploited, abandoned or subjected to corporal punishment. | Healthcare Supervisor/Community Nurse has scheduled an appointment with Individual #2's primary care physician to discuss weight loss. The soonest appointment available is scheduled for 12/17/24. Target date 12/31/24. |
12/31/2024
| Not Implemented |
| 6400.165(c) | Individual #2's Medication Omission August 23, 2024, at 0800
Medications not given:
- Lactulose
- Lamotrigine
- Omeprazole
- Almesartan
- Multivitamin
- Calcium-Vit D Supplement
- Debrox ear drops | A prescription medication shall be administered as prescribed. | A prescription medication shall be administered as prescribed. In addition, in absence of knowing whether this was a documentation error, or an actual medication error of omission, an incident should be entered into EIM indicating that a medication omission occurred on the date in question. The medication error was entered as EIM #9534659 (Attachment #7). |
12/13/2024
| Implemented |