| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(c) | Throughout the year, Individual #1's funds were used to purchase items that are to be covered by room and board. For example, 7/2 Individual #1's money was used to purchase bedding. On 9/27/23 and 9/29/23, their money was used to buy incontinence products. On 10/13/23, Individual #1's funds were used to buy bedding and on 10/20/23, their money was used to buy deodorant. | Individual funds and property shall be used for the individual's benefit. | Incident report was filed on 5/2/2024 and was completed on 5/14/2024. Residential Director, Residential Program Specialist, and Residential Coordinator were trained on regulation 6400.22(c) on 5/15/24 and 5/17/2024 by the Director of Quality Assurance, see Attachment # 23. Program Specialist sent an email to the Supports Coordinator to update the ISP in regard to Individual #1's spending habits, see Attachment# 24. Individual #1 will be reimbursed for all incontinence products purchased with their money. |
06/03/2024
| Implemented |
| 6400.22(d)(1) | In February and March 2024, Individual #1 received cash as spending money. Receipts were kept for the individual's purchases, but there was no cash log detailing what was spent. | 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 cash logs for February and March 2024 were obtained from Individual #1's record, see Attachment # 26. |
05/17/2024
| Implemented |
| 6400.43(b)(1) | The provider opened a number of new homes throughout the prior year. With the opening of each home, the provider is required to submit a completed self-inspection tool to ensure that all regulations are met. Staff #2 completed the self-inspection tools for the homes documenting there were no violations at any of the homes. This was not accurate, in that the homes had violations. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | Chief Executive Officer, Residential Director, Residential Program Specialist and Residential Coordinator were trained on regulation 6400.43(b)(1) on 5/15/24 and 5/17/24 by the Director of Quality Assurance, see Attachment # 28. |
05/20/2024
| Implemented |
| 6400.67(a) | At the time of the inspection, the water in the bathroom sink drained extremely slowly. | Floors, walls, ceilings and other surfaces shall be in good repair. | The bathroom sink was maintenance on 5/6/2024, a letter verifying that the work was completed by the property owner, see Attachment # 31. The Residential Coordinator was trained on Regulation 6400.76(a) on 5/15/2024 by the Director of Quality Assurance, see Attachment # 31a. |
05/15/2024
| Implemented |
| 6400.77(b) | At the time of the inspection, there was no tape available in the first aid kit. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | First aid tape was purchased and placed in the first aid kit on 5/1/2024, a picture was taken to show that the tape was added to the kit, see Attachment #32. |
06/03/2024
| Implemented |
| 6400.104 | (Repeat from 5/1/23 Inspection) The fire department notification letter dated 12/5/23 does not include the exact location of the individual bedrooms and a description of the mobility needs of the individual served. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Residential Program Specialist and Residential Coordinator were trained on regulation 6400.104 on 5/15/24 and 5/17/2024 by the Director of Quality Assurance, see Attachment # 34. Director of Quality Assurance developed a layout for each home showing the exact location of areas of the home including the individual(s) bedroom along with a photo of the home itself. The floor plan was developed on 5/13/2024 along with the picture of the home. Program Specialist updated the fire department letters on 5/6/2024. The fire department letter, floor plan and picture of the home was sent to the fire department on 5/13/2024, see Attachment # 35. |
05/17/2024
| Implemented |
| 6400.141(c)(8) | Individual #1 had a mammogram completed on 3/29/22 and not again until 6/8/23, outside of the annual timeframe. | The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. | The Program Specialist and Residential Coordinator was trained on regulation 6400.141(c)(8) along with the expectations of scheduling appointments within the required timeframes on 5/15/2024 and 5/17/2024 by Director of Quality Assurance, see Attachment #36. |
05/17/2024
| Implemented |
| 6400.144 | (Repeat from 5/1/23 Inspection) On 10/11/23, at a PCP appointment it was recommended that Individual #1's bowel movements are tracked. The tracking did not begin until 4/1/24. | 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.
| The Program Specialist and Residential Coordinator was trained on regulation 6400.144 along with touching base on how important is to follow physician's recommendations as well as touching on that constipation is one of the fatal 5 on 5/15/2024 and 5/17/2024 by Director of Quality Assurance, see Attachment #39. Program Specialist implemented a Bristol Stool tracking chart for tracking individual #1's daily BMs in May 2024, see Attachment # 40 |
05/17/2024
| Implemented |
| 6400.165(g) | (Repeat from 5/1/23 Inspection) Individual #1's quarterly Psych Med Reviews do not include the dosages of the meds. | 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. | The Program Specialist and Residential Coordinator was trained on regulation 6400.165(g) along with the expectations of scheduling appointments within the required timeframes on 5/15/2024 and 5/17/2024 by Director of Quality Assurance, see Attachment #41. |
05/17/2024
| Implemented |
| 6400.166(a)(2) | Individual #1's MARs did not include the prescriber for each medication. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | All prescribers were added to the MAR for May 2024, See Attachment # 43. The Program Specialist and Residential Coordinator was trained on regulation 6400.166(a)(2) on 5/15/2024 and 5/17/2024 by Director of Quality Assurance, see Attachment #44. |
05/17/2024
| Implemented |
| 6400.166(a)(4) | Individual #1 has an OTC PRN medication list. The PRNs were not documented 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. | All OTCs were added to the MAR for May 2024, See Attachment # 47. The Program Specialist and Residential Coordinator was trained on regulation 6400.166(a)(4) on 5/15/2024 and 5/17/2024 by Director of Quality Assurance, see Attachment #48. |
05/17/2024
| Implemented |
| 6400.166(a)(7) | The dose of the Olanzapine was documented as 7.5mg in May 2023. The correct dose of the Olanzapine was 10mg. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Dose of medication. | The Program Specialist and Residential Coordinator was trained on regulation 6400.166(a)(7) on 5/15/2024 and 5/17/2024 by Director of Quality Assurance, see Attachment #49. |
05/17/2024
| Implemented |