| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.113(a) | Annual fire safety training was not found in individual 2's record. Last fire safety training provided in record was dated 1/9/20 | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Based on the licensing review of November 8-9, 2021, the CLA Director, on 11/10/21, retrained the Program Specialists responsible for the completion of the fire safety trainings, as well as the Program Specialists Manager, about the importance of ensuring that the Fire Safety Training is completed within regulatory timeframes. |
11/19/2021
| Implemented |
| 6400.141(c)(14) | Information pertinent to diagnosis in case of emergency was listed on the physical exam for individual 2 as contact 911/ambulance. The information included should be pertinent to the individual's health should there be an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | Based on the licensing review of November 8-9, 2021, the CLA Director, on 11/11/21, retrained the Nurses and Healthcare Assistants about the importance of ensuring that consumer-specific medical information pertinent to the individual¿s diagnosis is on all physicals. All physicals from this point forward will contain the necessary data related to diagnosis. The Nurse is responsible to ensure all medical appointments/documentation are regulatory compliant. |
12/06/2021
| Implemented |
| 6400.144 | The most recent mammogram for individual 2 was 5/3/19. Path provided an internal document for 6/7/20, and 6/21/20 however, those appointments were not kept, and documentation of a rescheduled appointment was not found in the record to date. Follow up with the medical provider since 6/21/2020 was not provided by agency. | 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.
| Based on the licensing review of November 8-9, 2021, the CLA Director, on 11/11/21, retrained the Nurses and Healthcare Assistants about the importance of ensuring that consumer medical appointments are scheduled and completed per regulatory guidelines. Additionally, Nurses and Healthcare Assistants will seek appointments and when not available, documentation from the medical provider about any delays, following up with them every 15 days. The Nurse is responsible to ensure all medical appointments/documentation are regulatory compliant. |
11/20/2021
| Implemented |
| 6400.163(g) | Medication Erythromycin ointment, prescribed to individual 2, to be applied into right eye three times a day at 8am, 4pm and 8pm was discontinued on 11/2/2021 but still located in the medication box. Medication was not shown on the administration record as administered or discontinued in the month of November. | Prescription medications shall be stored in an organized manner under proper conditions of sanitation, temperature, moisture and light and in accordance with the manufacturer's instructions. | This citation was resolved immediately on 11/8/21, while licensors were still on site; the Site Supervisor removed the discontinued med from the medication box. Based on the licensing review of November 8-9, 2021, the CLA Director, on 11/10/21, retrained the Site Supervisors responsible for the sites, as well as the Assistant Directors about the importance of disposing of discontinued medication. It is the responsibility of the Site Supervisor to ensure discontinued medication is properly removed and disposed of as part of their weekly site visit. The residential staff at this site was also given verbal feedback about the importance of complying with 6400 regulations to assure that all discontinued medication is disposed of in accordance with the Federal and Staff statues and regulations (11.08.21). |
11/08/2021
| Implemented |
| 6400.166(b) | Escitalopram 20mg tablets and Ceravite advance tablet medication prescribed to individual 2 was not signed out immediately after administration at the 8am prescribed dose time on 11/8/2021. Pravastatin 40mg medication to be taken once daily at 8pm was inadvertently signed out at 8am on 11/8/2021. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | Based on the licensing review of November 8-9, 2021, the CLA Director, on 11/10/21, retrained the Site Supervisors responsible for the sites, as well as the Assistant Directors about the importance of ensuring that proper medication administration procedures are followed. On 11/9/21, staff was given immediate verbal feedback on how and when to properly document the MAR. On 11/18/21, the staff person was retrained by the site supervisor on how to properly administer and document medication. It is the responsibility of Site Supervisors to ensure that staff properly administer medications. |
11/18/2021
| Implemented |