| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(2) | Individual #4's financial record included spending that did not have input from the individual and the support team. | (2) Disbursements made to or for the individual.
| Policy and Procedure for Disbursement of Client Funds was issued on 2/1/2021.
Program Coordinator will complete transactions on Financial Ledger that will be specific to purchases made by clients.
Disbursements made directly to the individual will be clearly notated on the ledger.
Residential staff will track receipts to ensure clear documentation of purchases.
Significant purchases will be reviewed with the individual and treatment team members.
Attachment 6400.22(d)(2): Program Coordinator Job description, Policy and Procedure Disbursement of Client Funds, KC updated ledger for February. |
02/01/2021
| Implemented |
| 6400.67(a) | The blinds in the living room were damaged with some of the slats being broken or missing. | Floors, walls, ceilings and other surfaces shall be in good repair. | Service request for blind repairs was submitted on 1/14/2021.
Blinds were repaired on 3/29/21.
Senior Residential Advisor will complete weekly walk-throughs of apartments and identify any needs, completing Weekly Site Inspection Sheet.
A memo was issued to all administrative staff on completing Self-Assessment of apartments (utilizing ODP Self-Assessment tool) on a quarterly basis, dated 1/27/21.
All items that need repaired will be submitted to Director for follow up.
Attachment: 6400.67(a): weekly walk-thru, memo regarding Self-Assessment dated 1/27/21, Senior Resident Advisor job description; 6400.67(a) blinds |
03/29/2021
| Implemented |
| 6400.76(a) | The dressers in the bedrooms of individual's 2 and 3were missing knobs. | Furniture and equipment shall be nonhazardous, clean and sturdy. | Service request for dresser knobs was submitted on 1/14/2021.
Knobs were repaired.
Senior Residential Advisor will complete weekly walk-throughs of apartments and identify any needs, completing Weekly Site Inspection Sheet.
Memo to all administrative staff on completing Self-Assessment of apartments (utilizing ODP Self-Assessment Tool) on a quarterly basis, dated 1/27/21.
All items that need repaired will be submitted to Director for follow up.
Attachment: 6400.76(a): weekly walk-thru checklist, memo regarding Self-Assessment dated 1/27/21, Senior Resident Advisor job description; 6400.76(a) picture 1, 6400.76(a) picture 2 |
02/19/2021
| Implemented |
| 6400.143(a) | Individual #4 has not been seen by the dentist since 10/4/2017. There was no documentation regarding refusals as indicated by staff, provided at the time of inspection. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | A dental exam was completed for individual #4 on 1/27/2021.
All staff completed a training on Caring for Clients Medical Needs.
All staff were trained on the process of accompanying a resident to a medical appointment.
All staff reviewed process of documentation when a resident refuses medical care, including ongoing education and prompting for following health care needs and documentation.
Senior Resident Advisor will review documentation regarding medical appointments and refusals.
Program Director will review medical documentation a second time during monthly Program Book audits.
Attachment: 6400.143(a) individual #4 dental exam, Caring for Clients Medical Needs sign-off sheet, Senior Resident Advisor job description |
02/27/2021
| Implemented |
| 6400.144 | The following medications were not available in the medication box belonging to individual #4 during inspection: Triple Antibiotic Ointment, Milk of Magnesia, Robafen DM Liquid, Loperamide 2mg, Ibuprofen 400mg and Diphenhydramine. | 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.
| Policy and Procedure for CLA Monthly Medication Review was implemented and disbursed on 1/27/2021 (Attachment).
Pharmacy was contacted for verification on medications prescribed and medications discontinued.
Director will review MARs and medications for accuracy on a monthly basis.
Attachment: 6400.144: Policy and Procedure CLA Monthly Medication Review, 6400.144 picture 1, 6400.144 picture 2, 6400.144 picture 3 |
02/01/2021
| Implemented |
| 6400.186 | Individual #4's submitted information to licensing contained two 90-day reviews. Others were requested but were not received. | The home shall implement the individual plan, including revisions. | 90-day reviews were completed and in Program Books at time of inspection, but not placed in shared folder.
Program director will complete monthly reviews of program books to ensure accuracy and completion of needed documentation.
Attachment:6400.186 90-day reviews for KC 1/14/2020 and 4/14/2020. |
02/01/2021
| Implemented |