| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.68(c) | A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources' certified laboratory stating that the water is safe for drinking purposes at least every 3 months. A coliform test was completed on 2/16/23 and then not again until 6/6/23. This exceeds the requirement. | A home that is not connected to a public water system shall have a coliform water test by a Department of Environmental Resources¿ certified laboratory stating that the water is safe for drinking purposes at least every 3 months. Written certification of the water test shall be kept. | Provider's water testing laboratory went out of business with little notice. The provider established accounts with a new water testing laboratory and testing was done as quickly as possible but exceeded the quarterly requirement, resulting in a late water test. |
08/23/2023
| Implemented |
| 6400.144 | Health services, such as medical services that are planned or prescribed for the individual shall be arranged for or provided. Individual #1 had an ENT appointment on 12/3/21. The physician record form noted under prescribed treatment "see Dr. K. and refer to neurologist for balance f/u 3 months. The form also noted a return visit required on 3/16/22 at 10:45. There is no record or documentation that this appointment occurred. There is also no record or documentation for a neurologist appointment. Agency provided a 12/7/21 Dr. K, MD, appointment form to the licensing representative at the time of the inspection, and that appointment noted the reason for the visit was a follow up. | 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.
| An ENT appointment was scheduled immediately for individual #1. The appointment is 9/8/23. An appointment with the PCP was scheduled for 8/29/23 to discuss the referral to see a neurologist. |
08/25/2023
| Implemented |
| 6400.181(e)(13)(viii) | Individual #1's assessment dated 6/15/23 did not include the individual's progress over the last 365 calendar days in the area of managing personal property. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Managing personal property. | The Individual Assessment template was revised to include an area to report on progress and growth over the last 365 days on managing personal property. |
08/25/2023
| Implemented |
| 6400.165(f) | Individual#1 is prescribed Lorazepam 1mg tablet, 1 tab daily as needed for anxiety do not give w/in 1 hr of scheduled doses. There shall be a written protocol as part of the individual plan to address the social, emotional, and environmental needs of the individual related to the symptoms of the psychiatric illness. | If a medication is prescribed to treat symptoms of a diagnosed psychiatric illness, there shall be a written protocol as part of the individual plan to address the social, emotional and environmental needs of the individual related to the symptoms of the psychiatric illness. | A written protocol was immediately developed with prescribing physician to address the symptoms in which the PRN mediation should be used. Program staff have been trained in protocol. Assistant Vice President reviewed PRN medication orders for all individuals to ensure that protocols were in place for PRNs that address psychiatric needs. |
08/18/2023
| Implemented |