| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | Individual #1 is documented to be incontinent. In a review of the financial records for Individual #1 it was noted that "wipes" were purchased on multiple occasions from 9/1/23 to 9/30/24. As outlined in 6100.684(d)(x) Incontinence products, if the incontinence product is not covered by the individual's health care plan or another funding source it is included in the room and board paid to the provider. | Individual funds and property shall be used for the individual's benefit. | The affected individual will be reimbursed for the full amount of funds used from September 1, 2023, to September 30, 2024. |
10/14/2024
| Implemented |
| 6400.141(c)(4) | The physical for Individual #1 dated 7/26/24 noted that they are "followed by optho." There was no documentation to support that Individual #1 had been seen in 2023 or 2024.
The physical for Individual #1 dated 7/24/23 noted that Individual #1 had a "hearing aid" and "unable to obtain." There was no documentation to indicate that a hearing screening had been completed in 2023. Documentation noted an appointment completed on 1/17/24. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | The individual has been scheduled for a follow up annual screening on 1/14/2025, which will meet the regulatory requirements for annual examination. |
10/02/2024
| Implemented |
| 6400.181(a) | Records for Individual #1 indicate that annual assessments were completed on 1/31/22, 1/3/24 and 7/24/24. An assessment was not completed in 2023 as required. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | During our licensing review, it was demonstrated that the assessment was completed after the one-year timeline. This issue was identified during our newly established monthly meetings with program specialists. Our new Quality Assurance Manager, who leads these meetings, also runs weekly reports to ensure timely completion of assessments and reviews, ensuring compliance. |
10/02/2024
| Implemented |
| 6400.163(h) | At the time of inspection on 10/2/24 the Albuterol Sulfate located in the medication boxes for Pro Re Nata (PRN) medications was found to be expired. The expiration date on the manufacturers box was "Aug 24." The expired medication was not discarded as required. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Medication was discarded immediately after being discovered during licensing. |
10/14/2024
| Implemented |
| 6400.165(c) | At time of inspection on 10/2/24 the bottle of Fluticasone Propionate in use and over half full had a pharmacy fill date of 7/24/24. Pharmacy label directions indicate that the medication is to be administered as "2 puffs each nostril once daily." As directed 4 puffs would be administered daily. The manufacturer packaging notes that the bottle contains 120 metered sprays, enough for a 30 day supply. Administered as prescribed a new bottle would have been required by 9/1/2024. | A prescription medication shall be administered as prescribed. | Medications have been and will continue to be labeled in the order received to ensure orderly administration. We are emphasizing consistent reviews of medication fill dates and refill durations to maintain consistency in medication amounts. Although some medications are refilled within 28 days, potentially causing minor overstocking, we will ensure a close match between fill dates and expected durations |
10/14/2024
| Implemented |