| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.62(a) | Individual #1's Individual Support Plan (ISP) last updated 11/26/24 states that she does not understand the dangers associated with poisonous materials. Cleaning products are locked up in her home. Individual #2's ISP states that Individual #2 is not safe around poisonous materials. Individual #2''s CLA keeps all poisonous and cleaning materials locked ensuring that Individual #2 and her housemates will be unable to obtain such substances. Located in the closet in the main bathroom on the first floor of the home that was not locked was a container of Lysol disinfectant wipes and a container of Wipe Out antibacterial wipes and on the back of each of the containers labels it stated to call Poison Control Center. Located in the basement that was also unlocked on the counter next to the washer and dryer was a package of Tide Pods 3 in 1 and the back of the package stated to call Poison Control Center. On this same counter in the basement was 2 container of Arm & Hammer Oxi Clean liquid laundry detergent, and 2 containers of Tide simple All In One liquid laundry detergent and the back of all 4 of the laundry detergents states to contact a Physician. | Poisonous materials shall be kept locked or made inaccessible to individuals. | Staff locked all poisonous materials that are located in the basement and hall closet to ensure they are kept locked and made inaccessible to the individuals. Attachment #1 |
02/28/2025
| Implemented |
| 6400.62(c) | Poisonous materials shall be stored in their original, labeled containers. Located on the sink of the main bathroom on the first floor of the home was a Softsoap with the manufacturing labeling Aloe vera fresh scent. However, the liquid inside the container was a light red on top and a darker pink on the bottom of the container. When agency staff asked Staff#2 if they use another container to refill the soap container they stated, "they stated they do use another container to fill that one." | Poisonous materials shall be stored in their original, labeled containers. | Staff threw the soap container away to ensure all poisonous materials are stored in their original container/label. Attachment #3 |
02/28/2025
| Implemented |
| 6400.64(a) | The main floor bathroom sink had two areas in it with blue toothpaste was remaining in the sink and beginning to congeal and turn white the edges of the spots. Along the floor where the tub meets the tile was a black like substance resembling mold/mildew, The sink located in the basement had a coating on the bottom of it of what appeared to be lint. | Clean and sanitary conditions shall be maintained in the home. | Staff cleaned the bathroom sink and cleaned the mold/ mildew off around the base on the floor to ensure it is clean and in sanitary conditions. Staff will ensure to clean the bathroom on a daily basis. Attachment #4 & #5 |
02/28/2025
| Implemented |
| 6400.67(b) | At the time of the inspection, there was a door on the left side in Individual #3's bedroom that was unlocked. When you enter the unlocked door the left side of the room the wooden flooring is missing creating an approximate 1 foot to 1 ½ foot drop off on that side of the room. If an individual was to enter the room and fall this presents a hazard. | Floors, walls, ceilings and other surfaces shall be free of hazards. | Staff locked the attic door that is located in individual #3's bedroom is locked at all times. Attachment #6 |
02/28/2025
| Implemented |
| 6400.82(f) | At the time of the inspection, the main bathroom on the first floor and the bathroom on the second floor did not have individual clean paper or cloth towels. | Each bathroom and toilet area that is used shall have a sink, wall mirror, soap, toilet paper, individual clean paper or cloth towels and trash receptacle. | Staff placed paper towels in the main bathroom. Attachment #7 |
02/28/2025
| Implemented |
| 6400.141(c)(3) | Individual #'1's had a physical examination on 10/10/24 and their immunizations Tetanus/Diphtheria was left blank on the form. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Staff printed out Individual's #1 immunizations and attached them to her physical form. Attachment #8 |
02/28/2025
| Implemented |
| 6400.144 | Individual #1's 10/31/22 gyn appointment noted under treatment "colonoscopy due now-call Digestive Disease Associates. Individual #1's physical exam competed on 10/2/23 had an after-visit summary report attached to it from Tower Health Medical Group and it noted "ambulatory referral for colonoscopy." Individual #1 record showed they did not have an appointment with digestive disease associated until 2/12/25, and they aren't scheduled for a colonoscopy until 5/6/25. Individual #1's Over the counter (OTC) medication were not in the home. | 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.
| Karen had an appointment with digestive disease on 2/12/25 and is scheduled for her colonoscopy on 5/6/25. Threshold was able to get a copy of her last colonoscopy that was completed prior to her coming to Threshold on 7/25/2017. The findings of the colonoscopy were Normal upper endoscopy, one small polyp removed with cold biopsy, small internal hemorrhoids, otherwise normal colonoscopy to the cecum with a good preparation. Attachment #9 |
03/25/2025
| Implemented |
| 6400.216(a) | There was an unlocked closet in the hallway on the main floor and in this closet on the top shelf were separate binders with all the names of all of the individuals who reside in the home. A binder titled "all weights blood pressure" was on the shelf and another binder was titled blood sugars. The binders contained the individuals in the homes Protected Health Information (PHI). Also, in this unlocked closet was an unlocked filing cabinet that had the names of each individual in the home on each drawer, and inside each individual's drawer was a binder with their name and daily book as well as other file folders in the drawer specific to each individual. The outside of the drawer provided each of the individual's name information and PHI information content was inside each drawer for each individual. An individual's records shall be kept locked when unattended. | An individual's records shall be kept locked when unattended.
| Staff locked the hallway closet with the binders and PHI information to ensure individual's records are kept locked. Attachment #10 |
02/28/2025
| Implemented |
| 6400.52(c)(5) | There was no record or documentation that Staff #1 received annual training on the safe and appropriate use of behavior supports during the training year 7/1/23-6/30/24. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The safe and appropriate use of behavior supports if the person works directly with an individual. | Train all staff upon hire and annually thereafter. Attachment #11 |
11/30/2024
| Implemented |
| 6400.165(c) | According to February 2025 Medication Administration Record Individual #1's is prescribed Doxycycline Mono 50 mg, take 1 tablet by mouth once daily. Individual #1's medication pillow pack with the pharmacy label stated prescribed Doxycycline Mono 50 mg, take 1 tablet by mouth once daily. The medication was in a pillow pack with other medication and Staff #1 stated to the Licensing representative that she gives this medication to Individual #1 in applesauce. There was no directive on the medication to administer the medication in applesauce. The medication is not being administered as prescribed. | A prescription medication shall be administered as prescribed. | Staff contacted the prescribing doctor to have Individual's #1 medication changed to be given in applesauce. Attachment #12 |
03/25/2025
| Implemented |
| 6400.166(a)(4) | According to the Regulatory Compliance Guide (RCG) Over the Counter (OTC) medication medications must be recorded on the Medication Administration Record (MAR). According to Individual #1's record they have an OTC medication Approval form dated 10/10/24 for the following medications: Aspirin, Acetaminophen, Ibuprofen, Cough Drops, Cough Syrup, Mucus Relief, Cold/Flu caplets, Antacid (chewable), Anti-diarrheal medication, stool softener, Saine Enema, Anti-itch cream, Poison ivy preparations, antibiotic ointment/cream, antifungal cream/powder/spray, Sunscreen/sunburn preparations, dry skin lotion/ cream, and ear drops for wax removal. These medications were not listed on the MAR. The MAR did not include the name of the medication, strength of the medication, dosage form, dose of the medication, route of administration, frequency of administration, diagnosis, or purpose for the medication.
Individual #1' February 2025 Medication Administration Record (MAR) recorded Losartan, however Individual #1's medication pillow pack with the pharmacy label stated Losartan POT. The name of the medication did not match. Individual #1's MAR recorded oystershell and Individual #1's medication pillow pack with the pharmacy label stated OysterCal/Vit D. The name of the medication did not mach. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | OTC medication list was removed from the individual's records and will not be filled out with their annual physicals. |
03/25/2025
| Implemented |
| 6400.166(a)(5) | Individual #1's is prescribed Culturelle capsules and Individual #1's medication pillow pack with the pharmacy label stated Culturelle 10 BILCFU. However, Individual #1' February 2025 Medication Administration Record (MAR) only recorded Culturelle capsules it did not include the strength of the medication. Licensing Representative (LR) requested that the agency get clarification from the prescriber and pharmacy regarding the 10 BILCFU being the strength, but documentation was not provided to the LR so it can't be determined if the 10 BILCO is not the strength, and therefore should be recorded on the MAR as such. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Strength of medication. | Staff contacted the pharmacy due to the discrepancy between the MAR and the Pac strip. Pharmacy was able to correct and ensure the MAR and the Pac Strip match. Attachment #14 |
03/17/2025
| Implemented |