| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | The light at the front door was not functional. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| The front door light bulb was replaced. Front door light bulbs have built in dusk until dawn sensors. See attachment # 59.
The House Supervisor is responsible to conduct monthly Physical Plant Walk-Through of home. This form includes content of first aid kit. Form is to be given to Program Manager by 10th of each month. See attached procedure for physical Plant Walk-Through # 04 and completed form attachment # 55. |
07/30/2019
| Implemented |
| 6400.77(b) | Gauze and scissors were missing from the first aid kit. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | The Assistant Residential Director replaced the gauze and scissors in the first aid kit. See attachment# 58. The House Supervisor is responsible to conduct monthly Physical Plant Walk-Through of home. This form includes content of first aid kit. Form is to be given to Program Manager by 10th of each month. See attached procedure for physical Plant Walk-Through # 04 and completed form attachment # 55. |
07/25/2019
| Implemented |
| 6400.81(k)(6) | There was no mirror in Individual #1 and Individual #2 shared bedroom. | In bedrooms, each individual shall have the following: A mirror. | The Assistant Director purchased and hung a mirror in Individuals 1 and 2 bedroom. See photo: attachment # 57. The House Supervisor is responsible to conduct monthly Physical Plant Walk-Through of home. Form to be given to Program Manager by 10th of each month. See attached procedure for physical Plant Walk-Through # 04 and completed form attachment # 55. |
07/25/2019
| Implemented |
| 6400.82(e) | A non slip mat was missing from main bathroom. | Bathtubs and showers shall have a nonslip surface or mat. | The Program Director purchased nonslip strips for bathroom shower. Strips are installed in bathroom. See photo: attachment # 54. The House Supervisor is responsible to conduct monthly Physical Plant Walk-Through of home. Form to be given to Program Manager by 10th of each month. See attached procedure for physical Plant Walk-Through # 04 and completed form attachment # 55. |
07/25/2019
| Implemented |
| 6400.82(f) | The main bathroom did not have a towel or paper towels available. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | The House Chore List created by the Program Director implemented in all homes. Every shift at all homes have house chores, which includes ¿Ensure soap, towels are available in every bathroom and kitchen¿. This requirement is for Day, Evening and Overnight shifts. All staff instructed. House Supervisors monitor House Chore Document daily. See attachment # 56. |
07/25/2019
| Implemented |
| 6400.141(c)(7) | Individual # 1 record, there was no annual comprehensive gynecological exam completed or found in the record. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | Individual #1 has GYN appointment scheduled 10-9-19.
All Program Specialist were re-trained regarding 6400.141.
It is the responsibility of the residential Program Specialist and Nurse to schedule and confirm individuals have routine medical examinations. The residential Program will continue monthly Case record Review process in order to maintain compliance with regulations. The Residential Assistant Director is responsible to collect the monthly sample of case record reviews and report to the Director the percentage of compliance. All program Specialist are responsible to make all corrections and report to Residential Assistant Director a monthly update on progress towards compliance. |
10/09/2019
| Implemented |
| 6400.141(c)(8) | Individual #1 record, There was no record of an annual mammogram found in the record. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | Individual #1 had mammogram appointment on 8-26-19. Individual #1 refused. Second appointment is scheduled 9-9-19. If Individual #1 refuses on 9-9-19, the team will seek PCP approval for alternative testing. See Attachment #53.
All Program Specialist were re-trained regarding 6400.141.
It is the responsibility of the residential Program Specialist and Nurse to schedule and confirm individuals have routine medical examinations. The residential Program will continue monthly Case record Review process in order to maintain compliance with regulations. The Residential Assistant Director is responsible to collect the monthly sample of case record reviews and report to the Director the percentage of compliance. All program Specialist are responsible to make all corrections and report to Residential Assistant Director a monthly update on progress towards compliance. |
09/09/2019
| Implemented |
| 6400.166(d) | Individual #1 July 2019 Medication Administration Record Documents Clonazepam 0.5 MG Tab one tablet by mouth daily at 8PM was given on 6/14/2019 at 8PM then give again 6/14/2019. We don't know if medication was given twice on the same date
Individual #1 July 2019 Medication Administration Record Documents Clonazepam 0.5 MG Tab one tablet by mouth daily at 8PM was give July 15, 2019 in the AM and then given again July 15, 2019 at 8PM. We do not know if medication was given twice on the same date. | The directions of the prescriber shall be followed. | Upon further review it was discovered that the documentation was incorrect. The pill count reflects the medication being administered as prescribed. A medication error was entered into EIM (EIM # 8576080) See attachment # 52. |
07/18/2019
| Implemented |