| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.67(a) | There were multiple rust-colored stains on the drop ceiling in the bedroom hallway, located along the edges where the ceiling meets the wall, along the frame for the drop ceiling and near the ceiling light fixture. | Floors, walls, ceilings and other surfaces shall be in good repair. | On 7/16/22, the Program Service Lead (PSL) had the rust-colored stains on the drop ceiling in the bedroom hallway, located along the edges where the ceiling meets the wall, along the frame for the drop ceiling, and near the ceiling light fixture removed and or repaired. |
08/26/2022
| Implemented |
| 6400.73(a) | The handrail along the lower set of stairs leading to the front entrance of the home was loose and pulling out of the concrete. | Each ramp, and interior stairway and outside steps exceeding two steps shall have a well-secured handrail. | On 7/17/22, Spectrum Community Services maintenance repaired the loose handrail along the lower set of stairs leading to the front entrance of the home. |
08/26/2022
| Implemented |
| 6400.144 | The Individual is an insulin-dependent diabetic and is required to check her blood glucose levels daily. The Individual has a One-Touch Verio glucometer which records and saves the result; and staff record the results on a paper log. The glucometer's history did not show a test result for the following dates: 6/04/22, 6/09/22, 6/10/22, 6/11/11, 6/12/22, 6/13/22, 6/18/22, 6/19/22, 6/23/22, 7/03/22, 7/09/22 and 7/10/22. The paper logs were missing blood glucose readings for the same dates.
**There was conflicting documentation in the home regarding the frequency that the Individual's blood glucose should be tested. A diabetic protocol written 6/22/2022 by the agency states that testing should occur twice daily, prior to breakfast and dinner. The Individual's current Individual Support Plan (ISP) updated 7/06/2022, states that testing should occur three times daily, 15 minutes prior to breakfast, lunch and dinner. The history on the glucometer shows that testing occurred once per day, with a few exceptions. | 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.
| Effective 7/13/2022, the paper blood sugar tracker and protocol were reviewed with SEOP to discuss requirements for blood sugar testing. Staff reviewed and were retrained on blood sugar protocol including testing requirements. The Program Specialist sent the Diabetes protocol to SC and requested that ISP be updated to reflect current needs.
As of 8/18/22, blood sugar testing was added to the AccuFlo Medication system to ensure accurately timed documentation and accessibility for consistent management review. |
08/26/2022
| Implemented |
| 6400.32(r)(5) | The Individual has a key lock on her bedroom door but does not have a key to the lock. Staff did not have a key on their person and were not able to locate a key in the home. | Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door. | On 7/14/22, the missing key was found.
On 7/29/22, duplicate keys for individual bedroom door were made. One copy of the keys was given to the individual, and the second copy is stored at site. Staff are aware of the location of the key.
On 9/6/22, extra key was made and labeled. In addition, staff were counseled to always have individual¿s bedroom door key on them while on shift, and when a resident is present at the program. A copy of the key is stored in the CLA office where only staff have access to it. |
09/06/2022
| Implemented |
| 6400.207(4)(I) | The Individual is prescribed the antipsychotic medication CHLORPROMAZINE 200mg. to be administered as needed for agitation. There was no protocol or instructions indicating when this medication should be administered. There was no description of symptoms or behaviors that would direct staff when to administer the medication, if the Individual is able to request the medication, or who staff should contact for approval prior to administering the medication. Without a protocol to determine when and how the medication should be administered, it could be used as a chemical restraint for episodic adverse behavior. | A chemical restraint, defined as use of a drug for the specific and exclusive purpose of controlling acute or episodic aggressive behavior. A chemical restraint does not include a drug ordered by a health care practitioner or dentist for the following use or event: Treatment of the symptoms of a specific mental, emotional or behavioral condition. | On 7/14/22, the Psych PRN protocol was developed and sent to the Psychiatrist for review and signature. Effective 7/28/22, staff reviewed and were trained on the protocol. |
08/26/2022
| Implemented |