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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | (repeat from 1/29/24 inspection) The property record for individual #1 is not up to date. There were several purchases made over $50 that are not reflected on the property record, for example a purchase on 5/15/14 of a stained log rocker for $112.49 from Tractor Supply. | 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. | This regulation is important to keep track of and protect the people supported personal items that cost more than $50.
During the inspection, it was determined that a purchase that was over $50 was not tracked in Individual #1's property record.
This occurred because the organization did not have a process in place to ensure property records were being kept up to date.
Immediately following the inspection, all team members in the program received feedback to document all purchases of at least $50 or of sentimental value on the property records. The property record for Individual #1 was updated. See Attachment #15. |
02/21/2025
| Implemented |
| 6400.112(h) | During the fire drill conducted on 9/5/24, individual #1 did not evacuate to the designated meeting place. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | This regulation is important because it ensures all people supported know where to go in the event of a fire.
During the inspection, it was determined that Individual #1 did not evacuate to the designated meeting spot during the 9/5/2024 fire drill.
The team member did not ensure all people supported made it to the designated meeting spot during the fire drill. Additionally, the Quality Support Specialist did not recognize that the fire drill was not in compliance during their review. |
02/21/2025
| Implemented |
| 6400.141(c)(14) | Individual #1's current physical, dated 8/13/24, failed to identify individual #1's diagnosis of seizure disorder as medical information pertinent to diagnosis and treatment in case of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | This regulation is important to ensure all medically necessary diagnosis are listed on the person supported physical.
The physician failed to list individual #1's Seizure disorder as medically necessary information pertinent to diagnosis and treatment in the event of an emergency. The team members, program specialist, and agency nurse did not recognize this information was missing during their review of the annual physical.
Immediately following the inspection, the physician was contacted to amend the annual physical. See Attachment #17.
Since the Doctor has not yet responded, despite follow up phone calls to the physician's office, the residential supervisor will continue to call and ask for the physical to be updated. If there is no response by 2/24, the residential supervisor will take the document to the physician's office. In the meantime, there is a completed physical from 2/11/2025 for another individual to demonstrate compliance in this area. See Attachment #26. It should also be noted that the annual physical was updated since Individual #1 had his, and the new form provides more clarification on what should be documented for information pertinent to diagnosis.
In addition, the Program Specialist completed a review of all people supported to ensure information pertinent to diagnosis was indicated on their annual physical. This audit was completed on 2/14/2025. |
02/21/2025
| Implemented |
| 6400.144 | (repeat from 1/29/24 and 3/14/23 inspections) Individual #1 has a bowel/diverticulosis protocol in place. The current protocol states that the medical provider does not have to be contacted unless the individual has a change in bm, fevers, new or worsened pain in left lower abdomen, black or bright red bm's, or if there is no bm that has occurred in 8 days. No current documentation was provided to show that the physician was consulted regarding waiting 8 days with no bowel movement before taking any action. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| This regulation is important to ensure the health and safety of all people supported in regards to their medical needs. Protocols are used to train team members on what is needed to ensure medical recommendations are being followed.
The bowel protocol stated Individual #1 could go 8 days without a bowel movement before consulting the physician. There was not updated supporting documentation to support this information, and the medications related to their bowels have changed since the initial direction. Additionally, it is very uncommon for someone to go 8 days without a bowel movement before intervention.
Immediately following the inspection, the team received updated recommendations from the physician for an update to the protocol. The protocol has been updated to reflect the new recommendations. The team members have been trained on the new protocol. See Attachment #18.
Program Specialists completed an audit of all bowel protocols to ensure that they followed physicians' recommendations and did not allow people to exceed 4 days without a bowel movement. This audit was completed on 2/14/2025. |
02/21/2025
| Implemented |
| 6400.214(b) | At the time of the inspection on 1/29/25, the current ISP's and assessments were not available in the home for individual #1, #2, and #3. | The most current copies of record information required in § 6400.213(2)¿(14) shall be kept at the residential home.
| This regulation is important to ensure team members have access to ISPs/Assessments at all times for people supported.
The stie files were removed from the home and placed in the program manager's office in preparation for the annual inspection. The site files were not returned to the CLA in a timely manner, resulting in the assessments and annual ISP's not being present in the home.
Immediately following the inspection, the site files were taken back to the CLA. |
02/21/2025
| Implemented |
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.81(i) | During this inspection, individual #1's bedroom windows did not have drapes, curtains, blinds or shutters. There was no information in individual #1's plan as to why these items weren't present. | Bedroom windows shall have drapes, curtains, shades, blinds or shutters. | This regulation is important because window coverings provide individuals with privacy. Additionally, having drapes, curtains, blinds, or shutters on bedroom windows is normal household décor. Individual #1 did not have drapes, curtains, blinds or shutters on their bedroom window and there was no information in the ISP as to why these items weren't present. Individual #1 has previously stated that they do not want drapes, curtains, blinds, or shutters. Therefore, there was a film placed on the window for privacy. However, there was no documentation in the ISP indicating Individual #1 has chosen to not have drapes, curtains, blinds, or shutters. After receiving this citation, Individual #1 decided they wanted curtains. Individual #1 ordered curtains and they were hung on the bedroom window on 4/12/2022. See attachment #1.
Additionally, all Program Specialists will be completing an audit of all homes to ensure individuals have drapes, curtains, blinds, or shutters on their bedroom windows. If they do not, the Program Specialist will ensure there is a sentence in the individual plan that indicates they do not have drapes, curtains, blinds, or shutters on their bedroom windows with a brief explanation. In the event this information is not in the ISP, the program specialist will email the Support Coordinator and team to get the information added to the ISP. In the event the individual has previously chosen to not have drapes, curtains, blinds, or shutters on their bedroom windows, the Program Specialist will educate the individual on the option to have drapes, curtains, blinds, or shutters on their bedroom windows so they can make an informed decision. This audit will be completed by April 22, 2022. |
04/29/2022
| Implemented |
| 6400.81(k)(6) | During this inspection, Individual #1 did not have a mirror in their room. There was no information in individual #1's plan as why these items weren't present. | In bedrooms, each individual shall have the following: A mirror. | This regulation is important because it meets needs and desires of individuals and provides comfort. Additionally, having a mirror in a bedroom is normal household décor. Individual #1 did not have a mirror in their bedroom and there was no information in the ISP as to why a mirror wasn't present. This happened because the Program Specialist did not ensure the ISP indicated that a mirror was not in Individual #1's room and information that supports this decision.
Individual #1 did not have a mirror because the Individual has historically taken the mirror out of the room. Additionally, the Individual will destroy items when they are angry and the team felt it was unsafe to have a breakable mirror in the room.
Following this citation, the Program Specialist purchased a non-breakable wall mirror. On 4/11/2022, the mirror was placed on Individual #1's wall. See attachment #2.
Additionally, all Program Specialists will be completing an audit of all homes to ensure individuals have mirrors in their bedrooms. If they do not, the Program Specialist will ensure there is a sentence in the individual's plan that indicates they do not have a mirror in their bedroom with a brief explanation. In the event this information is not in the ISP, the Program Specialist will email the Support Coordinator and team to get the information added to the ISP. In the event the individual has previously chosen to not have a mirror, the Program Specialist will educate the individual on the option to have a mirror so they can make an informed decision. This audit will be completed by April 22, 2022. |
04/29/2022
| Implemented |
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