| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.141(c)(9) | Individual #1 had a prostate examination, completed on 7/30/18 and then again on 11/21/22. | The physical examination shall include: A prostate examination for men 40 years of age or older. | A tracking spreadsheet for medical exams was created on 1/30/2023, and includes tracking the dates of each individual¿s prostate exam to allow the program specialist to monitor the completion of a prostate exam. |
01/30/2023
| Implemented |
| 6400.15(b) | The agency used a Department's licensing inspection instrument modified in June 2018. The current licensing inspection summary instrument for the community homes for individuals with intellectual disability or autism regulations was promulgated in February 2020. | (b) The agency shall use the Department's licensing inspection instrument for the community homes for individuals with an intellectual disability or autism regulations to measure and record compliance. | The internal policy for self-assessment was updated on 1/25/2023 to include the current Provider self-assessment tool, and previously used forms were replaced on the shared drive with the correct form on the same date. The form was forwarded via email to the Chief Executive Officer and Program Specialist on 1/6/2023 with direction that this form should be utilized moving forward per inspection. |
01/25/2023
| Implemented |
| 6400.44(b)(2) | Individual #1's Individual Support Plan, last updated on 10/10/22, reads in the Meals/Eating section; "liquids should be thickened with nectar." Individual #1's physical examinations, completed 2/22/22 and 2/23/21 do not include special instructions for preparing liquids. Interviews reveal, Individual #1 consumes liquids through a straw. Program Specialist #1 is not assuming responsibiity for ensuring consistency and updates with individual #1's plan and care. | The program specialist shall be responsible for the following: Participating in the individual plan process, development, team reviews and implementation in accordance with this chapter. | The individual's primary care physician was contacted on 1/6/2023. The hospice team reviewed the individual's dietary needs and reported that though there was not previously an order for thickened drinks it would be safest to proceed with implementing the use of thickener with all beverages. The script for thickener was received and taken to the pharmacy. The script was filled and picked up on 1/12/2023. Employee of the house were individually notified of the change at the start of their first shift on site after 1/12/2023, and a house meeting was completed to review the individua's dietary needs on 1/20/2023. Documentation of this meeting is being retained by the program specialist and in the individual's file on site. |
01/20/2023
| Implemented |
| 6400.46(b) | The fire safety training provided to Direct Service Worker #2 on 7/11/22 did not include the evacuation procedures and designated meeting place that are specific to each of the homes. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | The fire safety training provided to employees does include the evacuation procedures and designated meeting place. However, is not being documented appropriately. The training documentation form will be updated by 2/10/2023 to include the evacuation procedures and designated meeting places that are specific to each home. |
02/10/2023
| Implemented |
| 6400.46(d) | Direct Service Worker #2 completed first aid, Heimlich techniques and cardio-pulmonary resuscitation training on 8/26/20 and again on 12/7/22. | Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a training by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. | All employees needing CPR in 2023 were signed up for a CPR course being held a minimum of 1 month prior to the expiration date of their CPR card. A document containing training dates was provided to site monitors and program specialists at a meeting on 1/19/2023. These were distributed to all other employees the same day via on site mailbox. |
01/19/2023
| Implemented |
| 6400.166(b) | Hydrocortisone 2.5% lotion, apply to facial rash at bedtime on Monday, Wednesday, and Friday, prescribed to Individual #1 was not initialed as administered on Wednesday, 12/28/22 at 8:00PM. Ketoconazole 2%, shampoo three times a week on Monday, Wednesday, and Friday prescribed to Individual #1 was not initialed as administered on Wednesday, 12/28/22. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | During the house meeting on 1/20/2023, program specialist reviewed the importance of initialing the MAR and completing checks that all MARs were initialed during medication administration. Program specialist reviewed the process for reporting missing initials on a MAR. Documentation of this meeting is being retained by the program specialist and in the individual¿s file on site. |
01/20/2023
| Implemented |