| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | Receipts submitted included the purchase of baby wipes on two separate occasions. 1/16/21 Walmart $13.61 and 11/24/20 Sam's $19.04. Incontinence supplies are included in Room and Board costs and are to be purchased by the provider. | Individual funds and property shall be used for the individual's benefit. | Individual #2 Individuals¿ funds were reimbursed on 4/9/2021. See attached documentation of reimbursement. |
06/15/2021
| Implemented |
| 6400.82(e) | There was no nonslip surface or mat in the large fully accessible bathroom. A nonslip surface or mat is required to ensure safety. | Bathtubs and showers shall have a nonslip surface or mat. | Nonslip mat was purchased and placed in the individual¿s bathroom shower on 3/22/2021. Attached is photo of nonslip mat. |
04/14/2021
| Implemented |
| 6400.112(g) | Sleep fire drills conducted on 10/10/20 at 1:00am and 4/18/20 at 12:50am. All fire drills must be held at different times of the day and night. | Fire drills shall be held on different days of the week and at different times of the day and night. | Program Specialist will ensure that fire drills are completed different days of the week and different times of the day and night. |
06/15/2021
| Implemented |
| 6400.181(e)(13)(i) | Assessment dated 8/5/20 noted that Individual #2 "she is on a "pureed diet and is on a strict organic diet." Individualized Feeding Plan dated 8/10/20 for Individual #2 indicated that consistency of food should be "pureed," posture during meals should be" sitting and must remain upright for 30 minutes after eating, drinking or receiving medication." After additional testing and evaluation, the Individualized Feeding Plan for Individual #2 was updated to reflect her current needs. The Individualized Feeding Plan dated 12/10/20 indicates that Individual #2 was now on a "Chopped ¼" unless otherwise specified" diet with "Thin liquids with controlled straw," posture should be "upright in chair at table 90', must remain upright for 30 minutes after eating, drinking or receiving medications." Other instructions included "small spoon a fork is best, controlled straw alternate solids with liquids, clear mouth between bite." The assessment was not updated as required to reflect the individual's current level. | The assessment must include the following information: The individual's progress over the last 365 calendar days and current level in the following areas: Health.
| Individual #2 Assessment was updated on 4/5/2021.
Assessment for Individual #2 is attached. |
04/30/2021
| Implemented |
| 6400.34(a) | Individual #2 was informed of her rights on 12/24/2020. The rights haven't been updated to reflect the current Chapter 6400 regulations. The missing rights include, lock bedroom door, and civil and legal rights afforded by law, make choices and accept risks, refuse to participate in activities and services, control their own schedule and activities, choice of roommate, furnish/decorate bedroom and common areas, a key, access card, keypad code or other entry mechanism accessible to the individual to permit the individual to lock and unlock the door, access to an individual's bedroom shall be provided only in a life-safety emergency or with the express permission of the individual for each incidence of access, assistive technology shall be provided as needed to allow the individual to lock and unlock the door without assistance. locking mechanism shall allow easy and immediate access by the individual and staff persons in the event of an emergency, primary caregiver shall have the key or entry device to lock and unlock the door entry mechanism to lock/unlock the front door, access to food, and make health care decisions. | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | The provider will review and update the policies and procedures regarding individuals¿ rights.
See updated Individual Rights Policy. |
06/15/2021
| Implemented |
| 6400.165(a) | The March 2021 Medication Administration Record (MAR) for Individual #2 included an entry for SAM-E 400mg. The MAR for SAM-E 400mg was written as "Take 1 tablet by mouth once daily with dinner." The MAR entry was documented as "O" on March 1st-10th. Documentation Code on the MAR indicates that "O" represents "not given (make comment)." Notation on the back of the MAR states that "SAM-E was not given because it was not provided due to the pharmacy not being able to get the supplement." Review of the February 2021 MAR for individual #2 shows that SAM-E was not given during the month with a notation on the back of the MAR "SAM-E out of stock." A review of the January MAR for Individual #2 indicates that the SAM-E was given from 1/1/21-1/11/21. MAR indicates that as of 1/12/21 the medication was not administered as prescribed. Notations on the back of the MAR include "SAM-E was not given because we don't have it." And "SAM-E was not given 1/29-1/31 due to not being at the house." Medications are to be administered as prescribed. | A prescription medication shall be prescribed in writing by an authorized prescriber. | SAM-E was obtained on 3/12/2021 and administered to Individual #2 at her next schedule dose.
Policy was developed to fill unavailable Medications. See attached. |
04/30/2021
| Implemented |
| 6400.166(a)(11) | The March 2021 Medication Administration Record (MAR) for Individual #2 does not include the diagnosis or purpose of the medication for any of the medications entered. Clobazam, Clonazepam, Ofloxacin, Organic Whey Protein, Triamcinolone Cream, Benzonatate, Ceravite, Coenzyme, Folic Acid, Vitamin B-12, Levetiracetam, Digestive Enzymes Caps, Fluticasone Prop, Levocarnitine, SAM-E and Ketaconazole did not contain a diagnosis or purpose for the medication as required. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | The provider will request from each individual doctor¿s their diagnosis for each of their medication.
The pharmacy will add the diagnosis to MAR¿S.
Attached is request for request of diagnosis for physicians. |
06/15/2021
| Implemented |