| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(a) | The Self-Assessment was completed on 2/6/23. The time frame for the self-assessment to be completed was from 11/1/22 to 2/3/23. | The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency's certificate of compliance, to measure and record compliance with this chapter. | Due to lack of knowledge of the regulation, assessors did not take into account both month and day when completing self-assessments. They were trained on Regulation 6400.15(a) on 5/17/2023. Attachment #1. |
05/24/2023
| Implemented |
| 6400.82(f) | At the time of the inspection completed on 5/3/23, the bathroom located off Individual #2's bedroom did not have paper towels, hand soap, or a waste basket. | 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. | Misunderstanding of what was needed in a restroom even if not being used. A waste basket, paper towels, and hand soap were placed in the bathroom at the time of inspection. Picture taken to show compliance. Attachment #40. Residential Coordinator was trained on regulation 82(f) on 5/17/2023. Attachment #41. |
05/24/2023
| Implemented |
| 6400.103 | (Repeat from Inspection completed 5/3/22) The written evacuation procedure developed did not identify the means of transportation or emergency shelter that would be used in the event of an emergency evacuation. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| The Program Specialist misunderstood the regulation. New Evacuation procedures were written to include all required information. Individuals and staff of the home were trained on the evacuation procedures as of 5/17/2023. Attachment #42. |
05/17/2023
| Implemented |
| 6400.104 | The letter sent to the fire department on 11/30/22 did not clearly identify the location of the individual's bedrooms. The letter indicated one individual lives in the home. Two individuals live in the home. | 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.
| Program Specialist error. The letter for this home was updated to include all correct information and sent to the local fire department on 5/9/2023. Attachment #20. |
05/17/2023
| Implemented |
| 6400.211(b)(1) | Individual #1's demographic information does not include the name, address, or phone number of their emergency contact. | Emergency information for each individual shall include the following: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency.
| Clarification error by the Program Specialist. Updated face sheet on5/17/2023. Attachment #43. |
05/17/2023
| Implemented |
| 6400.46(b) | Documentation was provided indicating that Staff #2 had fire safety training on 4/11/23. No documentation was provided verifying that Staff #2 had fire safety training prior to that date. Documentation was provided indicating that Staff #4 had fire safety training on 4/12/23. No documentation was provided verifying Staff #4 had fire safety training prior to that date. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | Unable to obtain fire safety training from 2022 for Staff #2 and #4. An agency Training Manager was hired in November 2022 and has taken over annual training for all programs at CCCC. |
05/17/2023
| Implemented |
| 6400.52(c)(6) | Staff #9-#15 were not trained on Individual #1's medication side effects. Staff #11-14 were not trained on Individual #1's most recent assessment. Staff #9 and #12 were not trained on Individual #1's health promotions. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual. | Staff were not signing off on necessary paperwork and the Residential Coordinator didn't catch this error when reviewing documentation. Staff #9, 10, 11, and 13 reviewed and signed off on required documentation. Attachments #46, #47 & #48. Staff #12, 14 & 15 are no longer working for the agency. Residential Coordinator was trained on regulation 52(c)(6) on 5/17/2023. Attachment #49. |
05/24/2023
| Implemented |
| 6400.165(g) | (Repeat from Inspection completed 5/3/22) The quarterly Psych Med Review completed on 3/1/23 does not include the dosages of the psych meds prescribed. | 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. | Dose was absent from the original Psych Med Review form. Form was updated to include the dose of medication. Program Specialist was trained on Regulation 6400.165(g) on 5/17/2023. Attachment #51. |
05/24/2023
| Implemented |
| 6400.167(a)(1) | Individual #1 is prescribed to receive a dose of Lorazepam 1 hour prior to a dental appointment. On 2/20/23, Individual #1 had a dental appointment. No Lorazepam was administered. It is not on the MAR. | Medication errors include the following: Failure to administer a medication. | Individual#1's plan for the use of Lorazepam was not clearly written as to when the medication was needed for the type of appointment. Program Specialist updated the protocol to clearly state when medication is needed and for the type of appointment it is needed for on 5/4/2023. Attachment #53. All staff were trained on the updated protocol by 5/16/2023. Attachment #48 |
05/17/2023
| Implemented |
| 6400.181(f) | Individual #1's assessment was completed on 3/21/23. The assessment was only provided to the individual and SC 30 days prior to the team meeting. None of the team members were provided a copy of the assessment 30 days prior to the team meeting. | The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting. | Program Specialist was not made aware of family members who attended the ISP prior to the meeting occurring. Program Specialist reached out to Supports Coordinator in regard to who are invited to Individual #1's ISP and was able to confirm who all was invited via email. Attachment #55. |
05/17/2023
| Implemented |
| 6400.261(a) | Individual #1 was in respite from 1/1/23 to 2/23/23. This exceeds 31 days in a calendar year. Once an individual is in a respite home for more than 31 days all regulations apply and are required. For example, the following regulations were to be completed on 2/1/23: Fire safety training for the individual, emergency medical plan, current photo, letter to fire department, staff training for the individual, MAR, release of information, and rights reviewed. | Respite care is temporary community home care not to exceed 31 calendar days in a calendar year. | Agency was told by the SC that Individual's respite was extended until 2/3/2023 and in error regulations were not followed on 2/1/2023. Moving forward whether respite payments are extended the agency will follow the 31 days in regard to Chapter 6400 regulations. |
05/24/2023
| Implemented |