| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.111(f) | On 4/7/23, the basement fire extinguisher did not include the date it had been inspected by a fire safety expert. | A fire extinguisher shall be inspected and approved annually by a fire safety expert. The date of the inspection shall be on the extinguisher. | The fire extinguisher was re-serviced and inspected on 04/21/2023 by ABC Fire Company. |
04/21/2023
| Implemented |
| 6400.141(a) | Individual #2's annual physical examinations were completed on 6/24/21 and subsequently on 7/12/22. | An individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Individual appointments are tracked in an Electronic Appointment Monitoring System within the Electronic Health Record system. This individual's next annual physical is scheduled for 07/12/2023. Training and transition to the new EHR system for the Nurse and Program Specialists began in January 2023 and is ongoing. This system tracks appointments and the status such as Scheduled, Not Scheduled, Completed, Results Pending, Cancelled, Missed, and Declined. Annual appointments will be tracked in this system and the following year's follow-up appointment and/or scheduling reminders will be linked to the previous year. Notifications for annual appointments will be set as high priority within the system to notify the team when annual appointments are upcoming and/or due to be scheduled. |
05/31/2023
| Implemented |
| 6400.141(c)(10) | Individual #1's physical examination completed on 12/13/22, did not indicate if they were free from communicable diseases or list specific precautions that must be taken to prevent the spread of disease to other individuals. This section was left blank. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | The Provider Nurse will contact the PCP to request recommendation related to the missing information and follow-up as recommended. |
05/31/2023
| Implemented |
| 6400.141(c)(13) | Individual #1's physical examination completed on 12/13/22 did not list allergies or contraindicated medication. This section was left blank. | The physical examination shall include: Allergies or contraindicated medications. | The Provider Nurse will contact the PCP to request recommendation related to the missing information and follow-up as recommended. |
05/31/2023
| Implemented |
| 6400.141(c)(14) | Individual #1's physical examination completed on 12/13/22 did not list medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. Individual #2's physical examination completed on 7/12/2022 did not list medical information pertinent to diagnosis and treatment in case of an emergency. This section was left blank. [Repeated Violation 4/26/22, et al] | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The Provider Nurse will contact the PCP to request recommendation related to the missing information and follow-up as recommended. |
05/31/2023
| Implemented |
| 6400.142(a) | Individual #2 had dental examinations completed on 11/17/21 and subsequently on 4/4/23. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Annual dental appointments will be tracked in the Electronic Health Record (EHR) Appointment Tracking system. Notifications will be set as high priority within the system to notify the team when the appointments are upcoming or it is time to schedule them. Any appointment that is missed, cancelled, rescheduled or refused will be tracked in the system as well and appointment refusal forms will be completed by the Program Specialist and reviewed with and signed by the individual to be uploaded and attached to the appointment in the EHR system. |
05/31/2023
| Implemented |
| 6400.151(a) | Regional Director #1, date-of-hire is 8/6/18 had a physical examination completed on 7/18/22. Regional Director #1's record was absent of any previously completed physical examinations, preventing the measurement of compliance. | A staff person who comes into direct contact with the individuals or who prepares or serves food, for more than 5 days in a 6-month period, including temporary, substitute and volunteer staff, shall have a physical examination within 12 months prior to employment and every 2 years thereafter. | The Human Resources Department is in transition from paper to electronic record system for staff and therefore the previous physical document has not been located and the electronic file located would not open. |
05/31/2023
| Implemented |
| 6400.181(a) | Individual #1, date of admission 9/14/22, had and initial assessment was completed on 3/24/23. [Repeated Violation 4/26/22, et al] | 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 Program Specialists will be re-trained on new admission intake process and documentation requirements. This will include updating the intake checklist form to provide check boxes and a space to document the due date of the initial Independent Living Assessment (ILA) 60 days from the admission date.
|
05/31/2023
| Implemented |
| 6400.34(a) | Individual #1, date of admission 9/14/2022 was informed and explained individual rights on 3/23/2023. Individual #2 was informed and explained individual rights on 1/28/2022 and subsequently on 3/18/2023. [Repeated Violation 4/26/22, et al] | The home shall inform and explain individual rights and the process to report a rights violation to the individual, and persons designated by the individual, upon admission to the home and annually thereafter. | The Program Specialists will be re-trained on new admission intake process and documentation requirements. This will include updating the intake checklist form to provide check boxes and a space to document date of completion for each section of the individual consents sections including the Individual Rights Review. The intake forms will be reviewed by the Program Manager on the day of admission for completion. The Program Specialist will also be re-trained on annual paperwork review requirements. |
05/31/2023
| Implemented |
| 6400.46(b) | Program Specialist #2 completed fire safety training on 4/7/21 and subsequently on 7/22/22. | Program specialists and direct service workers shall be trained annually by a fire safety expert in the training areas specified in subsection (a). | All training tracking will be transitioned to an electronic learning management system (ELMS) which notifies the staff person and their supervisor of training coming due and trainings that are overdue. The previous annual training information will be entered into the ELMS by the designated Administrative Assistant for each required course. The system will notify staff and their supervisor when the training is due and/or overdue moving forward. |
05/31/2023
| Implemented |
| 6400.52(c)(6) | Regional Director #1 provided direct care to individuals during the agency's 2022 calendar training year. Their annual training did not include the review of individual support plan(s). | 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. | The Regional Director will complete review of the individuals current support plans. The review and training will be documented and entered into the Electronic Learning Management System for annual tracking. |
05/05/2023
| Implemented |
| 6400.165(g) | Individual #2 is prescribed psychotropic medication. Three-month psychiatric medication reviews were completed on 4/6/22 and then again 9/7/22. | 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. | Quarterly appointments to review psychotropic medications will be tracked in the Electronic Health Record (EHR) Appointment Tracking system. Notifications for quarterly appointments will be set as high priority within the system to notify the team when the appointments are upcoming. Any appointment that is missed, cancelled, rescheduled or refused will be tracked in the system as well and appointment refusal forms will be completed by the Program Specialist and reviewed with and signed by the individual to be uploaded and attached to the appointment in the EHR system.
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05/31/2023
| Implemented |
| 6400.166(a)(11) | The following medications prescribed to Individual #1 did not indicate the diagnosis or purpose on the April 2023 Medication Administration Record: Fluticasone Spr 50mcg; Vilazodone tab 20mg; Vitamin B-12 tab 1000mg; Guanfacine tab 1mg; Quetiapine tab 40mg; Spironolact tab 25mg; Sucralfate Sus 1gm/10mL; Clanazep ODT tab 0.25mg; Divalproex tab 125mg DR; Omeprazole Cap 20mg; Pot Choloride tab 10meg ER; Cetaphil Gentle Liq; Sod Sul/Sulf Liq 9-4.5%; Clindamycin Gel 1%; and Hydrox Pam Cap 50mg. The following medications prescribed to Individual #2 did not indicate the diagnosis or purpose on the April 2023 Medication Administration Record: Aripiprazole 10mg tab; Atenolol 25mg tab; Basaglar Kwikpen 100 unit/mL; Duloxetine Cap 60mg; Losartan Pot tab 25mg; PEG 3350 Pow; Pot Chloride Pow 20meq; Novolog Inj Flexpen; and Senna Tabs 8.6mg. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | The Medication Administration Records(MARs) for both individuals have been updated to indicate the diagnosis or purpose of the medications identified during the review. The Provider Nurse also completed an audit of MARs for all other individuals served and updated MARs to reflect diagnoses or purpose as needed.
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04/18/2023
| Implemented |