| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Individual #1's December 2023 financial record indicates they made a purchase on 12/14/23 for $40.03. The corresponding receipt shows that the amount saved was $40.03 however and that the total purchase was -$4.00 because the individual had returned and re-purchased several items. There was $40.03 deducted from the individual's ledger when $4.00 should actually have been added. This caused the ending balance for December 2023 to be short $44.03 and all other subsequent balances to be incorrect. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | The record was corrected at the time of inspection. |
12/20/2024
| Implemented |
| 6400.80(a) | At the time of the 10/16/24 inspection, there was a large crack in the concrete sidewalk, which is a tripping hazard. | Outside walkways shall be free from ice, snow, obstructions and other hazards. | The large crack in the front sidewalk was repaired on 11/1/24. Photos of the repaired sidewalk are included in the supporting documentation folder titled walkway and walkway 2. |
12/20/2024
| Implemented |
| 6400.82(f) | At the time of the 10/16/24 inspection, there was no trash can or towels in the bathroom attached to the bedroom on the left side of the hallway. | 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. | A trash can and paper towels were placed in the bathroom off the bedroom on the left on 11/1/24. See photo of bathroom in Supporting documentation folder titled Bathroom. |
12/20/2024
| Implemented |
| 6400.144 | Individual #1 had a dental exam on 11/1/23 and it was recommended they have cleanings every 3 months. The next documented dental exam was not until 5/23/24 however. At the 5/23/24 appointment, it was recommended prophylaxis occur every 4 months and exams every 6 months. There is no documentation that the prophylaxis occurred at the 4 month mark.
Individual #1 has a history of bowel obstruction and bowel incontinence. The bowel management plan states they are prescribed bowel medications to assist with regulating their bowel movements. The individual tends to have 2 large bowel movements per week and that staff should document the BM's in Welligent. The bowel protocol is vague and gives limited direction as to when the PRN dosage of PEG 3350 should be administered. Furthermore, there was no bowel tracking completed from 6/29/24 through 7/9/24 or from 10/8/24 through 10/16/24. | 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.
| IMMEDIATE POC: The Program Specialist is attempting to reach Individual #1's dental provider, and they are not in the office until Monday, November 25th, 2024. The Specialist will reach out to the Provider on that date to determine if another appointment has already been scheduled or if one needs to be scheduled. When the appointment is scheduled and attended, clarification will be requested for the frequency of dental visits and future appointments will be scheduled for the next 6 months. Individual #1 has a PCP appointment scheduled for 11/22/2024 at 8:30 am and the staff will obtain the specifics for use of the PRN medication for the bowel management protocol. Staff will be trained on the protocol by the Program Specialist by 11/25/2024. The PD will communicate with the staff on the documentation standards for documenting on the bowel chart by 11/21/2024. |
12/20/2024
| Implemented |
| 6400.165(c) | Individual #1 is prescribed PEG 3350 powder as "mix 17gms in liquid and take by mouth every other day as needed for constipation/hard stools". The individual was not given this medication as prescribed as they received doses daily on 7/8/24 through 7/11/24, 7/15/24 & 7/16/24, 8/20/24 & 8/21/24, 8/29/24 & 8/30/24, 9/11/24 & 9/12/24, 10/2/24 & 10/3/24, and 10/10/24 & 10/11/24.
Individual #1 was prescribed Replesta wafer 5000 unit starting 9/4/24 as "Take 1 wafer by mouth every 14days for vitamin d deficiency". The individual was administered this medication every 7 days instead of every 14 days. The MAR shows this med as administered on 9/4/24, 9/11/24, 9/18/24, 9/25/24, 10/2/24, 10/9/24 and 10/16/24. | A prescription medication shall be administered as prescribed. | EIM reports entered for the med errors for the PEG 3350 Powder (#9522980) and the Replasta Wafer (#9523022) by the Program Director. The medication errors will be reviewed with staff on 11/25/2024 with the instructions gathered from the PCP at the 11/22/2024 appointment for the PRN PEG 3359 Powder, and the correction made to the eMAR for the frequency of administering the Replasta Wafer. The eMAR has been corrected to reflect the administration of the Wafer is to occur every 14 days by a Program Supervisor and the PD on 11/21/2024. |
12/20/2024
| Implemented |
| 6400.166(a)(4) | At the time of the inspection, individual #1 had a standing order form with multiple PRN medications listed. The medications were not listed on the MAR | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | The Program Specialist purchased the remaining missing standing orders meds on 12/27/2024. Medications were added to EMAR in EHR on 12/27/2024. See attachments of the Standing Order Medications and the eMAR with the OTC Standing Order meds. |
12/20/2024
| Implemented |