| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.77(b) | The first aid kit was missing the tweezers, thermometer, and scissors. | A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. | On 4/10/24 tweezers, thermometer, and scissors were placed in the First Aid kit. The Residential Supervisor will conduct training with group home staff regarding the review of First Aid kits and the process to request items if any are noted to be missing. Training will be completed by 5/31/2024. Documentation will be maintained in staff HR files. |
05/31/2024
| Implemented |
| 6400.77(c) | The first aid kit did not contain a first aid manual | A first aid manual shall be kept with the first aid kit. | On 4/10/24 a first aid manual was placed in the First Aid kit. The Residential Supervisor will conduct training with group home staff regarding the review of First Aid kits and the process to request items if any are noted to be missing. Training will be completed by 5/31/2024. Documentation will be maintained in staff HR files. |
05/31/2024
| Implemented |
| 6400.80(b) | The outside wood ramp has excessive large paint chipping on the entire surface and is need of repair. | The outside of the building and the yard or grounds shall be well maintained, in good repair and free from unsafe conditions. | On 4/11/24 a work order for repairs to the ramp was placed. Contracted maintenance staff will complete repairs by 7/1/2024.
Beginning May 2024 the Residential Supervisor will complete a monthly site monitoring form. This form will be sent to the Associate Director for review. Issue noted will be sent to the Manager of Facilities for follow up. |
07/01/2024
| Implemented |
| 6400.110(f) | Individual #1 requires a bed shaker and strobe lights for fire safety due to being hearing/visually impaired. The bed shaker was unable to detect the sound from the fire alarm and therefore was inoperable after 3 attempts to get it to work. A person with a body device and or pillow (for use when sleeping) that vibrates when the alarms sound, thus did not occur for the device currently being used. | If one or more individuals or staff persons are not able to hear the smoke detector or fire alarm system, all smoke detectors and fire alarms shall be equipped so that each person with a hearing impairment will be alerted in the event of a fire. | On 4/10/24 the bed shaker was repaired and tested to ensure proper functioning. The Residential Supervisor will conduct training with group home staff on reporting issues related to adaptive equipment. Training will be completed by 5/31/2024. Documentation will be maintained in staff HR files. |
05/31/2024
| Implemented |
| 6400.112(a) | There was no fire drill documented for the month of December 2023. | An unannounced fire drill shall be held at least once a month. | The Residential Supervisor will conduct training with Lead DSPs regarding the process for conducting monthly fire drills. Training will be completed by 5/31/2024. Documentation will be maintained in staff HR files.
The Associate Director will conduct training with Program Specialists regarding the process for verifying that monthly fire drills have been completed in compliance with regulatory requirements. Training will be completed by 5/31/2024. Documentation will be maintained in staff HR files. |
05/31/2024
| Implemented |
| 6400.141(c)(7) | Individual #1 has not had an OBGYN appt in a several years. It is stated in their record that her family does not want her to have an exam however they would need POA/Guardianship in order to make that determination. | 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 Associate Director will conduct training with Nursing regarding the regulatory requirements for medical appointments and documentation for individuals on their caseloads. Training will be completed by 5/31/24. Documentation will be maintained in staff HR files.
On 4/9/24 the program received correspondence from Individual #1¿s physician recommended deferring the gynecological exam indefinitely unless a problem presents that would require a GYN examination. A team meeting has been scheduled for 5/17/24 to review the physician¿s recommendations. |
05/31/2024
| Implemented |
| 6400.142(a) | On 6/2/23 individual #1 had a dental appointment, however this appointment was unsuccessful and no cleaning occurred. The individual was then referred to special smiles and has not yet been seen or scheduled which resulted in greater that 1 year between successful annual dental cleanings/exams. | 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. | The Associate Director will conduct training with Nursing regarding the regulatory requirements for dental appointments. Training will be completed by 5/17/24. Documentation will be maintained in staff HR files.
On 4/9/2024 Individual #1 `s PCP provided clearance for a dental appointment at Special Smiles. Pre sedation lab work was completed on 4/9/24, and an EKG is scheduled for 5/4/2024. Following the EKG, Special Smiles will schedule the dental appointment. |
05/17/2024
| Implemented |
| 6400.144 | The 10/23/23 Annual Physical Exam for individual #1 recommends seeing an ENT, this appointment had not yet occurred or been scheduled. | 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.
| Individual #1 has an ENT appointment scheduled for 5/31/2024.
The Associate Director will conduct training with Nursing on ensuring all components of the physical exam are completed in a timely manner including physicians¿ recommendations. Training will be completed by 5/17/24. Documentation will be maintained in staff HR files. |
05/17/2024
| Implemented |