| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.103 | The emergency evacuation plan does not describe the individual responsibilities in an emergency. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| The Program Specialist updated the homes emergency evacuation plan to include the responsibilities of the clients in the home. Program Supervisor trained the CCR in the home on the updated plan between 5/19/2022 & 5/24/2022, copy of the staff training log is Attachment # 4. The CCR will train any clients in the home as well as all staff working in the home between 5/19/2022 & 5/24/2022. A copy of the training log is Attachment # 8. |
05/25/2022
| Implemented |
| 6400.112(h) | The home has two designated meeting places, "corner of Peach St and Finch Alley or Corner of Peach St and Highland St" which could create confusion during an emergency. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | The Program Specialist updated the homes emergency evacuation plan to include the responsibilities of the clients in the home. Program Supervisor trained the CCR in the home on the updated plan between 5/19/2022 & 5/24/2022, copy of the staff training log is Attachment # 4. The CCR will train any clients in the home as well as all staff working in the home between 5/19/2022 & 5/24/2022. A copy of the training log is Attachment # 8. |
05/25/2022
| Implemented |
| 6400.141(c)(4) | At Individual #1's annual physical on 4/21/21 indicated Individual #1 should have further vision testing annually. At the time of the inspection, Individual #1 has not had additional vision screening. In addition, the vision was not screened at the annual physical completed on 4/22/22. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | New appointment was scheduled and completed on 5/26/2022 as Attachment # 9. PS , Program Supervisor and all CCRs were trained on regulation 6400.141c4 on 5/18/2022 & 5/25/2022 as Attachment # 10. |
05/25/2022
| Implemented |
| 6400.141(c)(12) | (Repeat from Inspection dated 6/29/21)-Individual #1's physical completed on 4/22/22 did not address the Individual's physical limitations. | The physical examination shall include: Physical limitations of the individual. | A form was sent to the PCP for review that included information for physical limitations, this was faxed on 5/12/2022. A copy of the completed signed form was received on 5/16/2022 as Attachment # 12. PS, Program Supervisor and all CCRs were trained on regulation 6400.141c12 on 5/18/2022 & 5/25/2022 as Attachment #10. |
05/25/2022
| Implemented |
| 6400.141(c)(13) | Individual #1's physical completed on 4/22/22 did not list the medications that the Individual is allergic to. | The physical examination shall include: Allergies or contraindicated medications. | A form was sent to the PCP for review that included all allergies and contraindicated medications, this was faxed on 5/12/2022. A copy of the completed signed form was received on 5/16/2022 as Attachment #12. |
05/18/2022
| Implemented |
| 6400.141(c)(14) | (Repeat from Inspection dated 6/29/21)-Individual #1's physical completed on 4/22/22 did not address the information pertinent to treat/diagnose in the event of an emergency. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | A form was sent to the PCP for review that included information for medical information pertinent to diagnosis and treatment in case of an emergency, this was faxed on 5/12/2022. A copy of the completed signed form was received on 5/16/2022 as Attachment #12. PS , Program Supervisor and all CCRs were trained on regulation 6400.141c14 on 5/18/2022 & 5/25/2022 as Attachment #10. |
05/25/2022
| Implemented |
| 6400.144 | Individual #1's record contained conflicting information regarding whether Individual #1 was to receive Miralax after 1 day with no bowel movement or 3 days with no bowel movement. Individual #1 is to receive Miralax after one day with no bowel movement. This went into effect on 1/26/22. From 1/26/22 to the present there were 25 days that Individual #1 had no bowel movement; but did not receive Miralax as per the BM protocol. There were three incidents in which Individual #1 went more then three days with no bowel movement. There is no documentation that Individual #1's doctor was called as per the recommendation on the daily documentation. | 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 PCP provided new guidance for BM protocol as Attachment #13. A new procedure was developed for constipation protocol as Attachment #14. Program Specialist will be trained on regulation 6400.144 on 5/18/2022 as Attachment #15. |
05/18/2022
| Implemented |
| 6400.181(e)(14) | Individual #1's ability to temper their own water is contradictory as to whether or not the Individual is capable of tempering their own water. In the "Supervision" section of the assessment it indicates the Individual is capable of tempering their own water. Under the "Knowledge of water safety/ability to swim section" it indicates the Individual is unable to temper their own water. | The assessment must include the following information:The individual's progress over the last 365 calendar days and current level in the following areas: The individual's knowledge of water safety and ability to swim. | The PS updated the assessment with an addendum to ensure that the ability to temper water is accurate and reads the same in all areas of the assessment. This was sent to the SC. The addendum is Attachment # 17. |
05/09/2022
| Implemented |
| 6400.15(b) | The Self-Assessment completed 2/28/22 did not indicate that regulations 52a1 and 52a2 were measured. | (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. | Director of Quality Assurance re-assessed the self-assessment and completed regulations 6500.52a1 and 52a1 on 5/6/2022 as Attachment #18. |
05/18/2022
| Implemented |
| 6400.165(g) | The quarterly Psychiatric Mediation Reviews do not include the reason for prescribing the medication. | 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. | Program Specialist has developed a new quarterly Psychiatric Mediation Review form that will include each medication along with the reason for prescribing each of the medications and if it should be continued, this form is being used now. |
05/25/2022
| Implemented |