| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | Individual #1 has a prescribed diet which notes that "meals are prepared in a ground manner." Financial records for Individual #1 noted the purchase of a Ganiza food processor in the amount of $29.99.
Equipment needed for food preparation is included in room and board costs. Individuals shall not be required to purchase items for the home, even if the individual will benefit from the item. | Individual funds and property shall be used for the individual's benefit. | Cash request was done and individual was reimbursed 29.99 for the food processor. |
11/25/2024
| Implemented |
| 6400.181(e)(13)(viii) | The assessment for Individual #1 dated 6/25/24 did not include a section to address the area of managing personal property as required. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | The template for the assessment we were using did not have this information on it. All program specialist were instructed to add this information on the current assessment. |
11/22/2024
| Implemented |
| 6400.32(i) | At the time of inspection all hair care accessories such as brushes, bows, and hair ties belonging to Individual #2, as identified by Staff #4, were locked in the hall closet of the home labeled "Personal Care."
The Individual #2 did not have access to all of their poison safe possessions as required. | An individual has the right of access to and security of the individual's possessions. | All personal items were removed from the hall closet and placed in the individual's bedroom. |
11/25/2024
| Implemented |
| 6400.165(g) | Three-month medication reviews for Individual #1 are documented as occurring on 7/15/24 and 11/7/24, this extends beyond the three-month timeline. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | House Managers were reminded that anyone that takes a medication to treat a psychiatric illness must see a licensed physician at least every 3 months. |
11/22/2024
| Implemented |
| 6400.166(a)(4) | Individual #1's Tylenol, Aloe Gel, Anti-Itch Cream, Aspirin, Pepto Bismuth, Desitin, Motrin, Robitussin and Bacitracin were not on the November 2024 Medication Administration Record (MAR) as required. As per the Regulatory Compliance Guide (RCG) Over the counter (OTC) medications must be recorded on the Medication Administration Record (MAR). The MAR did not include the name of the medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | All OTC's have been added to the medication logs. |
11/25/2024
| Implemented |
| 6400.207(5)(II) | Bed rails were noted to be in use for Individual #2. The bed rails extended across both sides of the bed and were engaged in the up position at the time of inspection. The bedrails rose above the mattress approximately 10 inches on both sides and extended within approximately twelve inches of the headboard and foot of the bed. The bedrails are in place to protect from injury during seizure activity. The physician's order does not include a plan for periodic relief of the device.
Per the Chapter 6400 Regulatory Compliance Guide The Department strongly recommends that bedrails not be used at any time for any purpose whatsoever. If bedrail use is observed and it is determined that the bedrail is not a mechanical restraint, the provider should be encouraged to obtain and use alternative devices to protect the individual's health and safety. | A mechanical restraint, defined as a device that restricts the movement or function of an individual or portion of an individual's body. A mechanical restraint includes a geriatric chair, a bedrail that restricts the movement or function of the individual, handcuffs, anklets, wristlets, camisole, helmet with fasteners, muffs and mitts with fasteners, restraint vest, waist strap, head strap, restraint board, restraining sheet, chest restraint and other similar devices. A mechanical restraint does not include the use of a seat belt during movement or transportation. A mechanical restraint does not include a device prescribed by a health care practitioner for the following use or event: Balance or support to achieve functional body position, if the individual can easily remove the device or if the device is removed by a staff person immediately upon the request or indication by the individual, and if the individual plan includes periodic relief of the device to allow freedom of movement. | During the meeting with Chris Hadley, he stated that these were approved. It was in his ISP and we had a doctor's appointment. In addition, he stated that we should have a doctor's note stating that we should receive something from the doctor stating when the individual would get some periodic relief for specific times. |
11/29/2024
| Implemented |