| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.113(a) | Individual #1, date of admission 12/16/23 was initially instructed in fire safety on 1/15/24. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Supervisors were trained on requirements for evacuation procedure training for transfers on 2/29/24. |
02/29/2024
| Implemented |
| 6400.141(c)(3) | Individual #1's most recent Tdap vaccination was administered on 1/19/09. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | The individual received a Tdap vaccination on scheduled on 3/1/24. All individuals immunization records will be reviewed by 3/15/24. |
03/01/2024
| Implemented |
| 6400.141(c)(4) | Individual #1's physical examination, completed 4/10/23 did not include a vision screening. | The physical examination shall include: Vision and hearing screening for individuals 18 years of age or older, as recommended by the physician. | The individual received a vision screening on 2/19/24 and hearing screening scheduled on 4/4/24. All individuals physical records will be reviewed by 3/15/24 and follow-up will be completed for anyone in need of a vision or hearing screening. |
02/19/2024
| Implemented |
| 6400.141(c)(6) | Individual #1's physical examination, completed 4/10/23 did not includeTuberculin skin testing. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | The individual received a TB test on 12/11/23. All individuals physical records will be reviewed by 3/15/24 and follow-up will be completed for anyone in need of a vision or hearing screening. |
03/15/2024
| Implemented |
| 6400.141(c)(7) | Individual #1's physical examination, completed 4/10/23 did not include a gynecological examination. | The physical examination shall include: A gynecological examination including a breast examination and a Pap test for women 18 years of age or older, unless there is documentation from a licensed physician recommending no or less frequent gynecological examinations. | The individual received a gynecological examination on 1/24/24. All individuals physical records will be reviewed by 3/15/24 and follow-up will be completed for anyone in need of a vision or hearing screening. |
01/24/2024
| Implemented |
| 6400.141(c)(12) | Individual #1's physical examination, completed 4/10/23 did not include physical limitations of the individual. | The physical examination shall include: Physical limitations of the individual. | The individuals doctor transferred information about her physical onto agency paperwork on 3/1/24. All individuals physical records will be reviewed by 3/15/24 and follow-up will be completed for anyone in need of additional information. |
03/01/2024
| Implemented |
| 6400.141(c)(13) | Individual #1's physical examination, completed 4/10/23 did not include allergies or contradicted medications. | The physical examination shall include: Allergies or contraindicated medications. | The individuals doctor transferred information about her physical onto agency paperwork on 3/1/24. All individuals physical records will be reviewed by 3/15/24 and follow-up will be completed for anyone in need of additional information. |
03/01/2024
| Implemented |
| 6400.163(h) | Clotrimazole and Betamethasone Dipropionate Cream USP, 1%/0.05% (base), apply topically to the vulva twice a day for 14 days, prescribed and dispensed to Individual #1 on 10/26/23, remained with Individual #1's current medications. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | All Site Supervisors were instructed on 2/29/24 to compare their MARs with PRN medications and time limited medications. Any medications which are no longer prescribed will be discarded no later that . Documentation for any discarded medication will be kept on the individuals Monthly MAR Disposal record. |
02/29/2024
| Implemented |
| 6400.165(c) | Per dentist's instruction, Vitamin D3 1000 IU (50mcg) prescribed to Individual #1, was not to be administer on 2/14/24 at 8:00AM due to Individual #1 having to be sedated for a tooth extraction. Direct Service Worker #1 initialed as administering this medication to Individual #1 on 2/14/24 at 8:00AM. | A prescription medication shall be administered as prescribed. | The DSP will be retrained by a Medication Administration Trainer on 3/4/24. A refresher training on documentation, omissions, and discontinuations was provided to the Site Supervisors by the Med Admin Trainers on 3/7/24. |
03/04/2024
| Implemented |
| 6400.166(a)(13) | Esomeprazole MAG CAP 40mg DR prescribed to Individual #1 was not initialed as being administered at 8:00AM on 2/14/2024. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication. | The DSP was retrained by a Medication Administration Trainer on 3/4/24 A refresher training on documentation, omissions, and discontinuations was provided to the Site Supervisors by the Med Admin Trainers on 3/7/24. |
03/04/2024
| Implemented |
| 6400.166(b) | Individual #1 is prescribed Vitamin D3 1000 IU (50mcg), which was initialed as administered by Direct Service Worker #1 at 8:00am on 2/14/2024. Per dentist's instruction, this medication was not to be administered this day due to Individual #1 having to be sedated for a tooth extraction. | The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered. | The DSP will be retrained by a Medication Administration Trainer on 3/4/24 A refresher training on documentation, omissions, and discontinuations was provided to the Site Supervisors by the Med Admin Trainers on 3/7/24. |
03/04/2024
| Implemented |