| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | The First Aid Kit did not contain Antiseptic. | 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. | The first aid kit box has been stocked with all of the above by the Direct Support Supervisor and a check was completed at all other CLA homes to ensure all are stocked with the listed items. |
06/06/2023
| Implemented |
| 6400.110(a) | The home did not have an operable smoke detector in attic. | A home shall have a minimum of one operable automatic smoke detector on each floor, including the basement and attic. | A smoke detector was installed by Maintenance Supervisor and team on 4/26/2023 - see attachment 2 |
04/26/2023
| Implemented |
| 6400.141(c)(6) | Individual 5 Last TB test was completed on 12/12/2020, no documentation was provided for current test. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | The individual had her TB test done on 12/22/22 - see attachment 4 |
12/22/2022
| Implemented |
| 6400.141(c)(7) | Individual 5 did not have a gynecological exam and no documentation of a refusal. | 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. | The individual does not tolerate gynecological examinations according to documentation from her doctor from 9/20/2018 and 12/5/2022. See Attachments 5 and 6 for notes from doctor. The doctor states that since the individual is not sexually active and a PAP exam would cause undue stress therefore not recommended. |
06/06/2023
| Implemented |
| 6400.141(c)(8) | No Mammogram was completed for Individual 5, and no documentation of a refusal provided. | 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. | The individual is currently 38 years old and it is noted on her annual PCP examination that it is not applicable at this time for her to have a mammogram (attachment 5). See attachment 7 for proof of her age. |
06/06/2023
| Implemented |
| 6400.142(a) | Individual 5 did not have a dental examination performed by a licensed dentist annually. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | The Program Specialist is in process of scheduling a dentist appointment for the individual. Completion date is no later than June 30, 2023. |
06/06/2023
| Implemented |
| 6400.142(g) | A dental hygiene plan was not rewritten at least annually for individual 5. | A dental hygiene plan shall be rewritten at least annually. | The dental hygiene plan was written on January 31, 2023 as indicated in attachment 11. |
01/31/2023
| Implemented |
| 6400.144 | The medication for individual 5 is not labeled on the MAR as indicated on the prescription. The MAR states DAILY Vite tablets and the individual is being administered MULTIVITAMIN 0. It could not be determined which medication is the correct medication to be administered. The medication KETOTIFEN FUMARATE prescription label does not match the MAR, the MAR states the med is for (itching) and the prescription states the med if for (allergies) | 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.
| The MAR has been revised to match the prescription label. (attachment 8+9) |
06/08/2023
| Implemented |
| 6400.181(a) | Individual 5's assessment was not completed annually. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | The independent living assessment was completed on 9/14/22 but was not signed. See attachment 12. The assessment has been dated as of 6/8/23. |
06/08/2023
| Implemented |
| 6400.181(d) | Individual 5's assessment was not dated by the Program Specialist. | The program specialist shall sign and date the assessment. | The independent living assessment was completed on 9/14/22 but was not signed. See attachment 12. The assessment has been dated as of 6/8/23. |
06/08/2023
| Implemented |