| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(d) | Four minutes and zero seconds is the home's maximum evacuation time determined by a fire safety expert on 10/28/21. The home exceeded this time on the following fire drills: 10/26/21 at 12:00 a.m. with an evacuation time of 4 minutes and 56 seconds; 01/25/22 at 04:38 a.m. with an evacuation time of 10 minutes 15 seconds. | Individuals shall be able to evacuate the entire building, or to a fire safe area designated in writing within the past year by a fire safety expert, within 2 1/2 minutes or within the period of time specified in writing within the past year by a fire safety expert. The fire safety expert may not be an employe of the home or agency. Staff assistance shall be provided to an individual only if staff persons are always present at the home while the individual is at the home. | All Fire Drills compliant at this time. Equipment for the individuals have been added to the home to ensure that Fire Drills can be completed in a more timely manner. Sit to stand lift and Gait belt can be used to encourage and assist individuals in getting up and exiting the home. |
09/21/2022
| Implemented |
| 6400.141(c)(6) | 6400.141d states: "Immunizations, vision and hearing screening and tuberculin skin testing may be completed, signed and dated by a registered nurse or licensed practical nurse instead of a licensed physician, certified nurse practitioner or licensed physician's assistant. Individual #1 had a Tuberculin evaluation completed on 8/7/22 that was completed by a Certified Medical Assistant (CMA). There was no documentation that the CMA had been trained to complete the Tuberculin evaluation. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Credentials of staff completing the TB are being checked for compliance as results come in to this provider by Human Resources for staff physicals and by the Program Specialist for individual physicals. If PCP allows the TB will be read by MCAR LPN or RN to ensure that valid credentials are reading the TB. IF the PCP states they must read the TB they will be notified that an RN, LPN, licensed physician, certified nurse practitioner or Licensed physicians assistant must read the TB. |
09/21/2022
| Implemented |
| 6400.181(e)(4) | Individual #1's assessment, dated 10/4/21, states that individual requires 24-hour staff supervision; however, Individual's Individual Support Plan (IPS), last updated 7/29/22, states that the individual requires 24 supervision, the individual can never be left alone in the home, and that staff should remain within hearing distance with 15 minutes visual checks. | The assessment must include the following information: The individual's need for supervision.
| All individual assessments will be check for accuracy on supervision levels to make sure there is consistency between the ISP. This will be completed by 12/19/22. Special attention will be paid to Assessment results, Progress over the last year, strengths and needs. These sections will be compared to MCAR individual demographics and details pages as well as the ISP to ensure that all information is synonymous. |
12/19/2022
| Implemented |
| 6400.165(g) | Individual #1 is prescribed medications to treat the symptoms of a diagnosed psychiatric illness. Individual had a psychiatric medication review completed on 11/12/21, and then again on 2/18/22, exceeding the 3-month requirement. | If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage. | Individual #1 had medication monitoring on 5/13/22 and 8/5/22. If the individual is unable to get in to see Psychiatrist for any reason for Medication monitoring and the medication has not been changed. Licensed physician will be contacted to confirm no changes in medication and this will be documented for the individual record. Individual will attend Psychiatric Clinic which occurs approximately every 90 days to ensure that they are on a proper medication monitoring schedule. |
09/21/2022
| Implemented |