Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
6400.112(f) | The front exit was used as the exit route for each fire drill conducted from 4/2024 through 1/2025. The home has two exits. | Alternate exit routes shall be used during fire drills. | Upon being notified of the violation by the state inspector on 2/26/2025, the program compliance specialist reviewed all fire drills from the current inspection period. On 3/6/2025, the agency updated their fire drill schedule to mandate the use of alternating exits (when applicable) each month |
03/21/2025
| Implemented |
6400.32(d) | On 2/26/2025 at 11:03AM, a paper that read, "540 Phone Restriction: 1. MT not to handle phone; 2. Staff to dial all numbers and put on speaker; 3. Monitor all calls; 4. Watch for repeated calls; DO NOT CALL WTAE [phone number with symbols on each side] Do Not Call [name and phone number]," was taped to the wall in the living room of the home. | An individual shall be treated with dignity and respect. | Upon being notified of the violation by the state inspector on 2/26/2025, the notice above the phone was immediately removed from the site. On 2/27/25 the Program Specialist reviewed with the individual ways in which it is important they are treated with dignity and respect. The Program specialist discussed grievance procedures and reporting though which the individual can report if they feel they are not being treated with dignity and respect. |
03/18/2025
| Implemented |
6400.34(a) | Individual #1 was informed and explained individual rights on 1/29/2023 and then again on 7/20/2024. This exceeds the annual requirement. [Repeat Violation 02/27/24 et.al.] | 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. | Due to Agency turnover, the agency identified lapses in compliance relating to the dates for reviewing individual rights. The agency implemented a tracking system on 1/8/24 however due to agency turnover the relevant information was not correctly entered in the tracking system. Beginning on 7/1/24 the agency conducted an audit of the review of individual rights for all individuals. Upon being notified of the violation by the state inspector on 2/26/2025, the Program Specialist immediately met with the individual to explain their rights. |
02/27/2025
| Implemented |
6400.50(a) | Program Specialist #1, date of hire 9/25/2024, completed orientation training on abuse, recognizing and reporting incidents and job-related knowledge and skills. Documentation of the date these trainings were completed was not provided. Direct Service Worker #2, date of hire 8/29/2024, completed orientation training on person-centered practices, community integration, individual choice, supporting individuals to develop and maintain relationships, abuse and individual rights. Documentation of the date these trainings were completed was not provided. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | Upon being notified of the violation by the state inspector on 2/26/2025, the program specialist #1 was assigned and completed the required training on 2/27/2025. The training was reviewed and filed on 2/27/2025. Additionally, the document that was not dated to show completion was reviewed and discussed with Direct Service worker #2 on 2/27/2025 to ensure they successfully completed this training, at which time the appropriate date was added to the training document. |
02/27/2025
| Implemented |
6400.163(a) | On 2/26/2025 at 11:17AM, a 1/2 tablet of Individual #1's prescribed medications, Risperidone, was at the bottom of a plastic storage bag inside the medication box | Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy. | Upon being notified of the violation by the state inspector on 2/26/2025, the agency staff immediately followed our Medication Disposal protocol and disposed of the pill in the correct way. The medication error was filed by the Program Specialist in EIM on 2/26/25 and staff was retrained following our Medication Error Protocol on 3/7/2025. |
03/07/2025
| Implemented |
6400.166(a)(11) | Individual #1's February 2025 Medication Administration Record does not include the diagnosis or purpose of the following medication: Buspirone HCL. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | Upon being notified of the violation by the state inspector on 2/26/2025, the agency staff immediately hand wrote the cut off diagnosis on the Medication Record. The following month¿s Medication Record was printed and shown to state inspectors that the cut off diagnosis was handwritten for future Medication Records. |
03/01/2025
| Implemented |