| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Individual #1's ISP indicates that poisonous material should be locked away. There was a can of Axe Body Spray in their bedroom and a tube of toothpaste in their bathroom, which are both considered poisonous materials. When this individual was placed at an alternate site during the inspection, the alternate site also did not have poisons secured. | Poisonous materials shall be kept locked or made inaccessible to individuals. | It is essential that all poisonous materials be kept locked and separate from food items. The team determined that the resident can safely handle and has the right to easily access toiletry supplies such as toothpaste, soap, body wash, deodorant, body spray The program specialist documented this addendum to the ISP and sent to the Supports Coordinator to update the ISP accordingly on 11/17/24. On 11/27/24 the SCO responded stating this was completed (Attachment #2). |
11/27/2024
| Implemented |
| 6400.81(k)(6) | Individual #1's bedroom did not contain a mirror. | In bedrooms, each individual shall have the following: A mirror. | All individuals served at CADES have the right and there is the expectation that they have a personalized bedroom with furniture in good condition, sanitary and tidy conditions, an area to store clothes, dresser, bed, and a mirror. CADES failed to meet this when individual 1's mirror was not available to him, and so a work order was placed to hang his mirror, and the mirror was rehung (Attachment #3). |
10/15/2024
| Implemented |
| 6400.105 | Trash bags containing blankets and clothing were stored in a lower kitchen cabinet in direct contact with the home's hot water heater. | Flammable and combustible supplies and equipment shall be utilized safely and stored away from heat sources.
| CADES failed to maintain safe, hazard free conditions to ensure the health and safety of the individuals by failing to ensure no clutter or debris which can be flammable, is around heat sources.
All items near the water heater were removed (Attachment #5). |
10/11/2024
| Implemented |
| 6400.144 | Individual #2 was missing the following PRN medications: Acetaminophen 325mg tablets, Anti-Dandruff Shampoo 1%, Geri-Tussin syrup DM | 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 requested a refill of the medications on 11/19/24 and will ensure that these are delivered to the site. Target date 11/25/24.
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. |
12/01/2024
| Not Implemented |
| 6400.171 | An open, unsealed can of sloppy joe sauce was stored in the fridge door and was open to potential contamination. | Food shall be protected from contamination while being stored, prepared, transported and served.
| Food that is not safely stored is subject to contamination and puts the individual¿s health at risk in the event of ingestion. CADES will ensure all food items in the home that are perishable are in the refrigerator or freezer, sealed, and that all food is labeled appropriately, and any expiration dates are followed with the food being thrown out.
All expired or incorrectly stored products in the refrigerator and pantry were disposed of (Attachment #7). |
10/11/2024
| Implemented |
| 6400.45(e) | Individual #1 was placed at a neighboring apartment while roommate individual #2 was taken to their day program. Due to the insufficient staffing and training at this alternate site, individual #1 was considered to be left unsupervised during this time. | An individual may not be left unsupervised solely for the convenience of the home or the direct service worker. | CADES cannot adjust plans to the needs of the staff or for convenience when transporting individual 2 to program, as that impedes on Individual 1's ability to make choice and determine where he will spend his day.
Correction made: Alternative transportation plan has been implemented for Individual #2. Individual 1 was counseled on it being his determination to visit his friends at neighboring apartments, and he will only be taken to neighboring sites, when it is his choice to do so (Attachment #1). |
11/22/2024
| Not Implemented |