| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | The home is not keeping up to date documentation of funds for the individual, a receipt for the amount of $34.42 was in the individuals record but not documented as deposited and or if this was the individual's funds or used for the individuals benefit. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | JEVS reimbursed the individual $34.42 since we could not explain what the expense was for. |
06/10/2024
| Implemented |
| 6400.113(a) | There is no evidence in the file that the individual is receiving fire safety training annually. Review of the file shows Individual One only received fire safety training on 6/16/2023. The individual has resided with provider since 2004. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | The individual received fire safety training on 7/17/24. |
06/17/2024
| Implemented |
| 6400.141(c)(10) | The annual physical completed on 11/3/2023 does not indicate whether Individual One is free of communicable diseases. The question appears on the form used by the provider and physician, however yes or no was not selected. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | The physician updated the physical for to include that MC is free of communicable disease on 6/19/24. |
06/19/2024
| Implemented |
| 6400.165(b) | Medication NATURAL FIBER POWER/ROBITUSSIN/DEBROX EAR DROPS (all expired 04/06/2024) | A prescription order shall be kept current. | All of the medications were discontinued by the physician on 6/25/24. They are not needed on an on-going basis and are not needed in the home. |
06/25/2024
| Implemented |
| 6400.166(a)(12) | Medication AMMONIUM LACTATE 12% LOTION was not administered to Individual One on 06/07/2024. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Date and time of medication administration. | Staff person received formal counseling for this error. All staff in the home were counseled on the importance of properly documenting medication when it is administered. |
06/13/2024
| Implemented |
| 6400.213(1)(i) | The Individual One file does not indicate any religious affiliation or non-affiliation. | Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number. | The fact sheet was corrected on 6/11/24 and includes all needed information including religious affiliation |
06/11/2024
| Implemented |