| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | The Annual Self Inspection for this location was not completed in the correct timeframe. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| The annual self-inspection was not completed within the time frame outlined in the 6400.15(a) regulations. The Operations Director will be retrained by the COO by 11/11/2024, on the proper time frame to complete annual self-inspections. Training is attachment #10 |
11/11/2024
| Implemented |
| 6400.22(d)(1) | Individual #1 does not have a current and up-to-date FS log, The transaction on 12/11/23 was documented as $75.83. It was only for $75.63. The transaction on 5/16/24 was documented as $46.07. The transaction was only for $46.04. | 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. | All EBT transactions are recorded on an electronic ledger after a purchase is made. The transactions
recorded on 12/11/23 and 5/16/24 were recorded incorrectly. A rep-payee database was put in place in SharePoint where all EBT transaction ledgers are uploaded monthly. The rep-payee will monitor the database and review all EBT ledgers monthly for accuracy. Training is attachment # 9 |
11/11/2024
| Implemented |
| 6400.22(e)(3) | Many receipts over $15 are missing from November 2023 through the present. | If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. | The provider strives to create an environment of self-determination for every person served in our program. All persons served are encouraged to manage their own money as much as is possible for that person. It is often difficult to get receipts after an independent purchase has been made. Program Managers will be trained to ask for duplicate receipts during the transaction as well as to involve the person in the electronic documentation in Therap. |
11/11/2024
| Implemented |
| 6400.110(c) | At the time of the inspection, there was not a smoke detector located in the common area of the home. | The smoke detectors specified in subsections (a) and (b) shall be located in common areas or hallways. | A smoke detector was installed in the common living area on 10/25/24. A picture of the installed smoke detector was taken and is attachment #4 |
11/11/2024
| Implemented |
| 6400.144 | (Repeat from 1/17/23, 11/28/23, 2/21/24) Individual #1 was to have their blood sugar checked Monday, Wednesday, and Friday through 10/2/24. Individual #1's blood sugar was not checked 11/6/23, 11/20/23, 11/24/23, 11/29/23, 12/6/23, 12/15/23, 12/25/23, 1/24/24, 8/14/24, and 9/13/24. Beginning on 10/2/24, the blood sugar was ordered to be tested daily. The blood sugar was not tested on 10/6/24, 10/14/24, 10/16/24, 10/20/24. | 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.
| All healthcare programs and plans are documented within Therap after completion of the procedure.
During the inspection on 10/22/24 it was discovered that multiple blood glucose checks were not
completed through the inspection year. The Program Manager will oversee the Therap databases
including all healthcare tracking to ensure compliance with documentation of glucose monitoring checks. |
11/11/2024
| Implemented |
| 6400.211(b)(3) | (Repeat from 11/28/23) Individual #1's demographic information did not include the name, address, and phone number of who to contact for medical consent. | Emergency information for each individual shall include the following: The name, address and telephone number of the person able to give consent for emergency medical treatment, if applicable.
| The Provider has started the transition from paper to electronic documentation. Part of
this transiton includes uploading the demographic information into Therap. The process for uploading
demographic information in Therap was started on 8/9/2024, in the interim, paper copies of the emergencyinformation demographic are kept in the program books. During this transition the demographic information sheet for individual #1 did not include the name address and telephone number for the to contact for consent. This was corrected and emailed to the ODP licensor on 10/24/24. |
11/11/2024
| Implemented |
| 6400.166(a)(4) | (Repeat from 11/28/23) Individual #1 has a standing order for over-the-counter PRN medications. The following medications on the standing order were not documented on the MAR: Kaopectate, Motrin, Ibuprofen, and Aller-Chlor | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of medication. | In reviewing the PRN standing order for individual #1 it was discovered that the October 2024 MAR did not list Kaopectate, Motrin or Aller-Chlor. After speaking with the pharmacist that fulfills individual #1's medication orders, it was stated that Kaopectate is the same medication as Pepto Bismal, Motrin is the same medication as Ibuprofen and Aller-Chlor is the same medication as Chlorpheniramine and the pharmacy viewed the PRN standing order as an either/or, not both when they fulfilled the order. The PRN standing order has been updated by the PCP to list only those medications they want delivered for PRN use. Ibuprofen was listed on the MAR for October. |
11/12/2024
| Implemented |
| 6400.166(b) | Individual #1's morning medication of Allopurinol was not logged immediately on 11/14/23. Individual #1's morning medication administrations were not logged immediately on 11/24/23. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | As a result of the ODP licensing inspection held on 11/28/23, Valley Community Services contracted with a new eMAR provider that was more user friendly and provided for ODP medication administration compliance. The new Therap eMAR was rolled out on April 1, 2024 during which time all previous noncompliance issues were resolved. Prior to 4/1/2024 the old eMAR system was still in use which is when these noncompliance violations occurred.
Valley Community Services will continue to follow all ODP medication administration regulations, including 6400.166(b) |
11/11/2024
| Implemented |
| 6400.167(a)(1) | Individual #1 did not receive their 8pm medications on 12/1/23: Atvorstatin, Benztropine, Divalproex 250mg, Divalproex 500 mg, Hydroxyzine, Metformin, and Olanzapine. | Medication errors include the following: Failure to administer a medication. | As a result of the ODP licensing inspection held on 11/28/23, Valley Community Services contracted with a new eMAR provider that was more user friendly and provided for ODP medication administration compliance. The new Therap eMAR was rolled out on April 1, 2024 during which time all previous noncompliance issues were resolved. Prior to 4/1/2024 the old eMAR system was still in use which is when these noncompliance violations occurred. Valley Community Services will continue to follow all ODP medication administration regulations, including 6400.167(a)(1). |
11/11/2024
| Implemented |