| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(a) | There was not fire drill completed for 2/2024. | An unannounced fire drill shall be held at least once a month. | This was an error which cannot be resolved due to the fact that February has already passed. The maintenance plan below will address this to ensure it does not happen again in the future. |
07/01/2024
| Implemented |
| 6400.112(e) | The provider did not complete a 6-month asleep drill at least every 6 months. There was a drill completed in September 2023 and the next drill was completed in April 2024. | A fire drill shall be held during sleeping hours at least every 6 months. | This was an error. Fire drills were completed monthly but the schedule of the overnight drills was changed which caused a lapse in the time period the drill should have been completed, resulting in more than 6 months between overnight drills. This is a past violation which cannot now be resolved, but the maintenance plan below will ensure future compliance. |
05/01/2024
| Implemented |
| 6400.142(a) | Individual #2's most recently completed dental appointment occurred on 3/1/23. There was a 6 month follow-up planned on 9/18/23, however a family member canceled this, and the next follow up is scheduled for 5/1/24. A 6 month follow up was recommended however this has gone over a year. | 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 5/1/2024 dental appointment was completed (Attachment #11). |
07/15/2024
| Implemented |
| 6400.144 | Individual #2's medication Clindamycin 1% gel was on the MAR but said to have been discontinued for a while. | 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 medication is ordered as PRN, but it was transcribed on the MAR as routine. The informant who notified the inspector that the medication had been discontinued was mistaken. The Primary nurse transcribed the medication as PRN on the April Medication Administration Record and the Pharmacy was notified of the change for the May Medication Administration Record (Attachment 12). |
07/31/2024
| Implemented |
| 6400.181(a) | Individual #2's two most recent annual assessments occurred on 1/26/22 and 12/5/23 | 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 Program Specialist will ensure Individual #2's next assessment is completed on or before 12/5/2024. Subsequent assessments will be scheduled for completion within 1 year from the last assessment. |
07/01/2024
| Implemented |
| 6400.34(a) | Individual Rights for individual #2 did not have a date so it cannot be determined if they received the training within the last year. The most recent completed individual rights statement occurred on 2/12/23 | 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. | Individual #2's rights were reviewed with them on 5/15/24 (Attachment #13). |
07/31/2024
| Implemented |
| 6400.167(a)(1) | Individual #2's medication, Refresh Eye Drops were not given on 4/2/24, 4/3/24, 4/4/24 and then after it was discontinued on 4/12/24, it was administered once on the evening pass. | Medication errors include the following: Failure to administer a medication. | Medication was removed from the site upon discovery on 4/24/2024. The primary nurse ensured the pharmacy was aware of the discontinued medication, which was not included in the May 2024 Medication Administration Record (Attachment #14). |
07/31/2024
| Implemented |