| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.142(f) | Individual #1 does not have a written dental hygiene plan. | An individual shall have a written plan for dental hygiene, unless the interdisciplinary team has documented in writing that the individual has achieved dental hygiene independence. | Provider completed individual #1 dental hygiene plan on 7/6/2023 (see attachment #12). |
07/06/2023
| Implemented |
| 6400.144 | Individual #1's supervision care needs state there are to be breath of life checks completed overnight every 30 minutes as well as checked/changed/repositioned a minimum of every 2 hours. There is no documentation that these checks are being completed. | 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 provider has created a medication administration treatment record to ensure that overnight supervision needs are met. (see attachment #13). Staff will document on the treatment record every 30 minutes for the breath of life checks and document on the treatment record for every 2 hours checked/changes/repositioned. The medical department, director, and team supervisors were trained on this regulation on 7/11/23 (see attachment #2-this will be sent to licensing as the plan of correction was due 7/10/23). |
07/11/2023
| Implemented |
| 6400.145(1) | Emergency medical plan identified for this home is not person specific. The Emergency Medical Plan states that staff will utilize the closest hospital to the home unless emergency personnel or a licensed physician indicates otherwise. This hospital or source of health care must be based on the preference of the individual or their substitute decision maker unless honoring the request puts the individual at risk of harm. | The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. | Individual number 1s Emergency Medical Plan was completed (see attachment #14) |
07/06/2023
| Implemented |
| 6400.181(a) | Individual #1's date of admission was 11/16/2022. The individual's initial assessment was not completed until 1/18/2023, which exceeds the 60 calendar days after admission. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the residential home and an updated assessment annually thereafter. The initial assessment must include an assessment of adaptive behavior and level of skills completed within 6 months prior to admission to the residential home. | The provider realizes this citation cannot be corrected. The program specialist and director were trained on this regulation on 7/6/23 (see attachment #5) |
07/06/2023
| Implemented |
| 6400.181(d) | Initial assessment completed on 1/18/23 upon Individual #1's admission was not signed by the program specialist. Additional assessment updates that have been completed on 2/16/23 and 3/21/23 are also not signed by the program specialist. | The program specialist shall sign and date the assessment. | Individual #1 annual assessment was signed and dated by program specialist and individual on 6/23/23 (see attachment #15) |
07/06/2023
| Implemented |
| 6400.50(a) | Staff #1 was trained on Individual #1's ISP on 6/9/23, however there is no length of training included. | Records of orientation and training, including the training source, content, dates, length of training, copies of certificates received and staff persons attending, shall be kept. | The provider realizes this citation cannot be corrected. A new form was given to the program with length of training to start utilizing asap (see attachment #16). All team supervisors, program specialist, medical, and director were trained on this regulation on 7/6/23 and 7/11/23. (see attachments #5 and #2 will be sent as plan of correction was due 7/10/23) |
07/11/2023
| Implemented |
| 6400.182(c) | Individual #1's diet plan changed on 3/9/2023, however the ISP was not updated at the time of the change. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | The program specialist completed an email to the supports coordinator on 6/21/2023 with the correct diet to include in the ISP. (see attachment #17) |
07/06/2023
| Implemented |
| 6400.183(c) | There is no list of persons who attended Individual #1's ISP meeting held on 1/3/2023. | The list of persons who participated in the individual plan meeting shall be kept. | The provider realizes this citation cannot be corrected. A sign in sheet was given to the program to start utilizing asap (see attachment #16). All team supervisors, program specialist, and director were trained on this regulation on 7/6/23 and 7/11/23. (see attachments #5 and #2 will be sent as plan of correction was due 7/10/23) |
07/11/2023
| Implemented |
| 6400.196(c) | Individual #1's diet order was changed on 3/9/2023 however there is no documentation that staff were trained on the changed order. | Documentation of the training provided, including the staff persons trained, dates of training, description of training and training source, shall be kept. | The staff were trained on 6/28/23. (see attachment #22) |
07/06/2023
| Implemented |