| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.113(a) | There was no Previous Fire Safety training for individual #1 | 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. | Individual #1 had a new Fire Safety Training completed on 1/7/2023. Going forward, all indivduals that reside in the program will have a new Fire Safety Training completed by 7/1/2023 by the Program Specialist/House Manager. Beginning on 9/1/2023 all indivduals will have an annual Fire Safety Training completed at their annual Individual Service Plan (ISP) which includes; being 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. The Program Specialist will ensure the training is completed, documented and included in the ISP. |
07/01/2022
| Implemented |
| 6400.141(c)(14) | The most recent annual physical for individual #1 was missing information pertinent to diagnosis and treatment in case of emergency. The section designated for this information on the form was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The current annual physical for indivduals #1 was sent to the primary care physician office on 5/24/2023 for completion of the section; Information pertinent to diagnosis and treatment in case of emergency. A follow up notification was made on 6/9/2023 to gather the revised document. The primary care physician¿s office faxed the completed revised physical with all information completed on 6/15/2023. |
06/15/2023
| Implemented |
| 6400.144 | The following medications prescribed to individual #1 were not present at the time of inspection:
Blistex PRN
Diazepam 10 MG tab PRN
Triamcinolone .1% ointment PRN | 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.
| The Health Care Coordinator reorder the missing PRN medications (Diazepam and Triamcinolone) for indivdual #1 on 5/23/2023. The Blistex PRN was discontinued by the Primary Physician on 5/23/2023. The two other medications were received in the home on 5/23/2023. |
05/23/2023
| Implemented |
| 6400.166(b) | On 5/23/23 the prescription Clonidine .2mg 8 AM for individual #1 was logged as "Medication not available" however the medication was given. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | After review of individual #1 medication record on 5/23/2023, the Medication Observer according to the Office of Developmental Programs Medication Training Course determined the logging of the medication for indivdual #1 was a documentation error. The medication was given and the logging of the medication was in error (logging a 1 is defined as the medication given, logging 11 is defined as the medication was not available in the facility). Facility documentation error forms were completed for individual #1 and sent to the Quality Management Coordinator for review. |
05/24/2024
| Implemented |