| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.112(a) | (Repeat Violation from 2/1/21)-- Individual #1 and Individual #2 moved into this home on 4/28/21. There was no fire drill completed in 4/2021. The first fire drill that was conducted in this home was on 5/13/21. | An unannounced fire drill shall be held at least once a month. | All staff members at the home were retrained on 3/02/2022 in the requirement of having a Fire Drill completed upon moving into a new home or location. All staff were retrained on this regulation and communication about why this regulation exists and why we are required to have the fire drill take place upon moving into a new location
was completed with all staff. The retraining for all staff members at this location is attached to this Plan of Correction. |
04/30/2022
| Implemented |
| 6400.113(a) | (Repeat Violation from 2/1/21)-- Individual #1 and Individual #2 moved into this home on 4/28/21. Fire safety training was not completed for either individual related to this home until 1/4/22. | 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. | All staff members at the home were retrained on 3/02/2022 in the requirement of having Fire Safety Training completed upon moving into a new home or location. All staff were retrained on this regulation and communication about why this regulation exists and why we are required to have the fire safety training take place upon moving into a new location was completed with staff. The retraining for all staff members at this location is attached to this Plan of Correction. |
04/30/2022
| Implemented |
| 6400.217 | At the time of the 2/7/22 inspection, there is not a release of information on filed that is signed by Individual #1's legal guardian. | Written consent of the individual, or the individual's parent or guardian if the individual is 17 years of age or younger or legally incompetent, is required for the release of information, including photographs, to persons not otherwise authorized to receive it.
| Individual #1 had an updated Release of Information document completed inside the Electronic Health Record which was reviewed with the individual and reviewed with the individual's legal guardian and signed by the legal guardian on 2/25/2022. The new Release of Information Documents that have been reviewed and signed by the individual's legal guardian are attached to this Plan of Correction. |
04/30/2022
| Implemented |
| 6400.165(g) | (Repeat Violation from 2/1/21) -- There is no documentation maintained that Individual #1's quarterly medication reviews were completed by a licensed physician on the following dates: 3/18/21, 9/16/21, and 12/16/21. The documents provided to the department were notes completed by Community Services Group with no acknowledgement or signature from a medical professional. Additionally, the need to continue medications was not addressed on the 3/18/21 appointment documentation. | 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. | All staff members, supervisors, managers and specialists at the home were retrained on 03/02/2022 on the required items that are needed on all Psychiatric Medication Review Forms and that the Supervisor and Manager are responsible to ensure that all Medical Appointment Forms have the correct and required information listed for each Medical Appointment Forms. Attached is a Quarterly Psychiatric Medication Review Appointment Form that took place after Licensing to show the form completed with the required information and this will be how all Quarterly Psychiatric Medication Review Forms will be completed moving forward to ensure no further issues take place with this regulation. We also had communication with the Psychiatrist to ensure that they understand
what information we need completed for each form and the need for required doctor's signatures and dates on each form. |
04/30/2022
| Implemented |
| 6400.167(a)(4) | Individual #1 received the following medications more than 1 hour after the prescribed time on 1/21/22: Fiberlax, Lamotrigine, Miralax, Olanzapine, Oxcarbazepine, Probiotic, Stool softener, Vitamin D3. | Medication errors include the following: Failure to administer a medication at the prescribed time, which exceeds more than 1 hour before or after the prescribed time. | Individual #1's Electronic MAR was reviewed for any other medication issues and this Medication Administration was previously reported and documented in the EIM System for these medications being administered late on this date and time. All staff members, supervisors, managers and specialists at the home were retrained on
03/02/2022 on regulation 167 and the need to follow medication administration regulations at all times and report all medication errors when they take place. The EIM Report Summary has been printed from the EIM System and attached to this Plan of Correction and the Training signature sheet is attached from the staff retraining on this regulation. |
04/30/2022
| Implemented |