| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The agency's self-assessment windows of completion are the following: 5/23/24 to 8/3/24 and/or 3/28/24 to 6/28/24. The home's self-assessment was completed from 9/12-13/24. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter.
| CLASS Quality and Compliance Coordinator (QCC) will complete quarterly self-assessments of houses. Residential house managers (RHM) will complete monthly house inspections. The self-assessment windows will be placed on the corporate calendar for continuity of completion and to ensure that dates are being met. |
12/31/2024
| Implemented |
| 6400.15(c) | The agency completed the home's self-assessment from 9/12-13/2024. The following violations were identified with no written summary of corrections: .20b, .34a, .112a, .112b, .112c, .112d, .112e, .112f, .112g, .112h, .112i, .141a, .141c4, .141d, .142a, .142b, .142c, .142d, .213(3) and .213(4). | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| CLASS Quality and Compliance Coordinator (QCC) will complete quarterly self-assessments of houses. Any identified violations will be corrected and a new self-assessment will be completed showing compliance. |
12/31/2024
| Implemented |
| 6400.112(c) | The written record of the fire drills conducted on 5/17/24, 6/20/24, 7/18/24, and 8/6/24, did not document the exit route used. | A written fire drill record shall be kept of the date, time, the amount of time it took for evacuation, the exit route used, problems encountered and whether the fire alarm or smoke detector was operative. | Residential homes managers were all retrained on the regulations pertaining to fire drills. Fire drill log forms were updated with exit route used and reviewed with all residential homes managers on 10/3/2024. |
12/31/2024
| Implemented |
| 6400.32(r)(1) | At 12:21 PM on 9/26/24, Individual #1's bedroom door was equipped with a thumb- turn lock. Interviews revealed that Individual #1 did not have a designated mechanism to lock and unlock the door. At 12:23 PM on 9/26/2024, Individual #2's bedroom door was equipped with a thumb-turn lock. Interviews revealed that Individual #2 did not have a designated mechanism to lock and unlock the door. At 12:24 PM on 9/26/24, Individual #3's bedroom door was equipped with a thumb-turn lock. Interviews revealed that Individual #3 did not have a designated mechanism to lock and unlock the door. | Locking may be provided by a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door. | Locks were changed to straight locks on bedroom doors |
12/31/2024
| Implemented |
| 6400.32(r)(5) | At 12:21 PM on 9/26/2024, Individual #1's bedroom door was equipped with a thumb- turn lock. Interviews revealed that staff did not have a designated mechanism to lock and unlock the door. At 12:23 PM on 9/26/24, Individual #2's bedroom door was equipped with a thumb-turn lock. Interviews revealed that staff did not have a designated mechanism to lock and unlock the door. At 12:24 PM on 9/26/24, Individual #3's bedroom door was equipped with a thumb-turn lock. Interviews revealed that staff did not have a designated mechanism to lock and unlock the door. | Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door. | Locks were changed to straight locks on bedroom doors |
12/31/2024
| Implemented |
| 6400.163(d) | At 12:16 PM on 9/26/24, the key to the staff office where medications are kept was stored in plain sight, hanging from a thumb tack on the wall directly outside the office, rendering the medication accessible. | Prescription medications and syringes, with the exception of epinephrine and epinephrine auto-injectors, shall be kept in an area or container that is locked. | Keys were removed from the current location and are now kept on the staff on duty's person at all times. Staff will hand off keys during shift changes. |
12/31/2024
| Implemented |
| 6400.166(a)(4) | Individual #1's September 2024 Medication Administration Record did not include the medication's name for the prescribed, Scopolamine. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | Program Specialists reviewed all medications, medication labels, and medication administration records to ensure that all medications were properly documented. |
12/31/2024
| Implemented |
| 6400.166(a)(5) | Individual #1's September 2024 Medication Administration Record did not include the strength of the prescribed, Scopolamine. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | Program Specialists reviewed all medications, medication labels, and medication administration records to ensure that all medications were properly documented. |
12/31/2024
| Implemented |
| 6400.166(a)(6) | Individual #1's September 2024 Medication Administration Record did not include the dosage form of the prescribed, Scopolamine. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dosage form. | Program Specialists reviewed all medications, medication labels, and medication administration records to ensure that all medications were properly documented. |
12/31/2024
| Implemented |
| 6400.166(a)(7) | Individual #1's September 2024 Medication Administration Record did not include the dose of the prescribed, Scopolamine. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | Program Specialists reviewed all medications, medication labels, and medication administration records to ensure that all medications were properly documented. |
12/31/2024
| Implemented |
| 6400.166(a)(8) | Individual #1's September 2024 Medication Administration Record did not include the route of administration for the prescribed, Scopolamine. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Route of administration. | Program Specialists reviewed all medications, medication labels, and medication administration records to ensure that all medications were properly documented. |
12/31/2024
| Implemented |
| 6400.166(a)(9) | Individual #1's September 2024 Medication Administration Record did not include the frequency of administration for the prescribed, Scopolamine. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Frequency of administration. | Program Specialists reviewed all medications, medication labels, and medication administration records to ensure that all medications were properly documented. |
12/31/2024
| Implemented |
| 6400.166(a)(10) | Individual #1's September 2024 Medication Administration Record did not include the administration times for the prescribed, Scopolamine. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Administration times. | Program Specialists reviewed all medications, medication labels, and medication administration records to ensure that all medications were properly documented. |
12/31/2024
| Implemented |
| 6400.166(a)(11) | Individual #1's September 2024 Medication Administration Record did not include the diagnosis or purpose for the prescribed, Scopolamine. | 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. | Program Specialists reviewed all medications, medication labels, and medication administration records to ensure that all medications were properly documented. |
12/31/2024
| Implemented |
| 6400.207(5)(III) | On 9/26/24 at 11:58 AM, Individual #1's bed contained half bed rails that restrict the movement or function of the individual's body. The agency did not obtain a prescription from a medical practitioner for the bedrails. The most current assessment, dated 8/30/24, does not address 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. The individual plan, most recently updated 9/4/24, does not include periodic relief of the device to allow freedom of movement. On 9/26/24 at 12:00 PM, Individual #2's bed contained a half bed rail on the right side against the wall that restricted the movement or function of the individual's body. The agency did not obtain a prescription from a medical practitioner for the bedrail. The individual plan, last updated 8/13/24, does not include periodic relief of the device to allow freedom of movement. On 9/26/24 at 12:36 PM, Individual #3's bed contained full bed rails that restricted the movement or function of the individual's body. The agency did not obtain a prescription from a medical practitioner for the bedrails. Interviews revealed that Individual #3 did not need the bed rails and only had them because the bed had belonged to a previous individual who occupied the bedroom. | 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: Protection from injury during a seizure or other medical condition, 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. | Residential homes manager is working with the primary care doctor to get a copy of orders for the bed rails. Assessments will be completed to assess the needs for bed rails. Individual #3 bed rails have been removed. |
12/31/2024
| Implemented |